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1.  Recurrent Dislocation of the Shoulder Joint 
Dr. Anthony F. DePalma is shown. Photograph provided with kind permission of the Art Committee of Thomas Jefferson University, Philadelphia, PA.
Dr. DePalma was the first editor of Clinical Orthopaedics and Related Research, established by the recently formed Association of Bone and Joint Surgeons. The idea of forming the Association of Bone and Joint surgeons had been conceived by Dr. Earl McBride of Oklahoma City in 1947, and organized by a group of twelve individuals (Drs. Earl McBride, Garrett Pipkin, Duncan McKeever, Judson Wilson, Fritz Teal, Louis Breck, Henry Louis Green, Howard Shorbe, Theodore Vinke, Paul Williams, Eugene Secord, and Frank Hand) [9]. The first organizational meeting was held in conjunction with the 1949 Annual Meeting of the AAOS [9] and the first annual meeting held April 1–2, 1949 in Oklahoma City. Drs. McBride and McKeever invited Dr. DePalma to attend that meeting and join the society. According to DePalma, “Even at this small gathering, there were whisperings of the need of another journal to provide an outlet for the many worthy papers written on clinical and basic science subjects” [7]. The decision to form a new journal was finalized in 1951, and Drs. DePalma and McBride signed a contract with J.B. Lippincott Company. Dr. DePalma was designated Editor-in-Chief, and the journal became a reality in 1953 with the publication of the first volume. From the outset he established the “symposium” as a unique feature, in which part of the articles were devoted to a particular topic. Dr. DePalma served as Editor for 13 years until 1966, when he resigned the position and recommended the appointment of Dr. Marshall R. Urist. At his retirement, Clinical Orthopaedics and Related Research was well established as a major journal.
Dr. Anthony F. DePalma was born in Philadelphia in 1904, the son of immigrants from Alberona in central Foggia, Italy [1]. He attended the University of Maryland for his premedical education, then Jefferson Medical College, from which he graduated in 1929. He then served a two-year internship (common at the time) at Philadelphia General Hospital. Jobs were scarce owing to the Depression, and he felt fortunate to obtain in 1931 a position as assistant surgeon at the Coaldale State Hospital, in Coaldale, Pennsylvania, a mining town. However, he became attracted to orthopaedics and looked for a preceptorship (postgraduate training in specialties was not well developed at this time before the establishments of Boards). In the fall of 1932, he was appointed as a preceptor at the New Jersey Orthopaedic Hospital, an extension of the New York Orthopaedic Hospital. In 1939 he acquired Board certification (the first board examination was offered in 1935 for a fee of $25.00 [2]) and was appointed to the NJOH staff [1].
Dr. DePalma volunteered for military service in 1942, and served first at the Parris Island Naval Hospital in South Carolina, then on the Rixey, a hospital ship. In addition to serving to evacuate casualties to New Zealand, his ship was involved in several of the Pacific island assaults (Guam, Leyte, Okinawa). In 1945, he was assigned to the Naval Hospital in Philadelphia [1].
On his return to Philadelphia, he contacted staff members at Jefferson Medical College, including the Chair, Dr. James Martin, and became good friends with Dr. Bruce Gill (a professor of Orthopaedics at the University of Pennsylvania, and one of the earliest Presidents of the AAOS). After he was discharged from the service, he joined the staff of the Department of Orthopaedic Surgery at Jefferson, where he remained the rest of his career. He succeeded Dr. Martin as Chair in 1950, a position he held until 1970 when he reached the mandatory retirement age of 65. He closed his practice and moved briefly to Pompano Beach, Florida, but the lure of academia proved too powerful, and in January, 1971, he accepted the offer to develop a Division of Orthopaedics at the New Jersey College of Medicine and became their Chair. He committed to a five-year period, and then again moved to Pompano Beach, only to take the Florida State Boards and open a private practice in 1977. His practice grew, and he continued that practice until 1983 at the age of nearly 79. Even then he continued to travel and lecture [1].
We reproduce here four of his many contributions on the shoulder. The first comes from his classic monograph, “Surgery of the Shoulder,” published by J. B. Lippincott in 1950 [2]. In this article he describes the evolutionary development of the shoulder, focusing on the distinction between various primates, and relates the anatomic changes to upright posture and prehensile requirements. The remaining three are journal articles related to frozen shoulder [1], recurrent dislocation [3], and surgical anatomy of the rotator cuff [6], three of the most common shoulder problems then and now. He documented the histologic inflammation and degeneration in various tissues including the coracohumeral ligaments, supraspinatus tendon, bursal wall, subscapularis musculotendinous junction, and biceps tendon. Thus, the problem was rather more global than localized. He emphasized, “Manipulation of frozen shoulders is a dangerous and futile procedure.” For recurrent dislocation he advocated the Magnuson procedure (transfer of the subscapularis tendon to the greater tuberosity) to create a musculotendinous sling. All but two of 23 patients he treated with this approach were satisfied with this relatively simple procedure. (Readers will note the absence of contemporary approaches to ascertain outcomes and satisfaction. The earliest outcome musculoskeletal measures were introduced in the 60s by Larson [11] and then by Harris [10], but these instruments were physician-generated and do not reflect the rather more rigorously validated patient-generated outcome measures we use today. Nonetheless, the approach used by Dr. DePalma reflected the best existing standards of reporting results.) Dr. DePalma’s classic article, “Surgical Anatomy of the Rotator Cuff and the Natural History of Degenerative Periarthritis,” [6] reflected his literature review and dissections of 96 shoulders from 50 individuals “unaware of any (shoulder) disability” and mostly over the age of 40. By the fifth decade, most specimens began to show signs of rotator cuff tearing and he found complete tears in nine specimens from “the late decades.” He concluded,
“Based on the…observations, one can reasonably construct the natural history of periarthritis of the shoulder. It is apparent that aging is an important etiological factor, and with aging certain changes take place in the connective tissue elements of the musculotendinous cuff…it is also apparent that in slowly developing lesions of this nature compensating adjustments in the mechanics of the joint take place so that severe alterations in the mechanics of the joint do not appear. However, one must admit that such a joint is very vulnerable and, if subjected to minor trauma, the existing degenerative lesion would be extended and aggravated.”
Thus, he clearly defined the benign effects of rotator cuff tear in many aging individuals, but also the potential to create substantial pain and disability.
Dr. DePalma was a prolific researcher and writer. In addition to his “Surgery of the Shoulder,” he wrote three other books, “Diseases of the Knee: Management in Medicine and Surgery” (published by J.B. Lippincott in 1954) [4], “The Management of Fractures and Dislocations” (a large and comprehensive two volume work published by W.B. Saunders in 1959, and going through 5 reprintings) [5], and “The Intervertebral Disc” (published by W.B. Saunders in 1970, and written with his colleague, Dr. Richard Rothman) [8]. PubMed lists 62 articles he published from 1948 until 1992.
We wish to pay tribute to Dr. DePalma for his vision in establishing Clinical Orthopaedics and Related Research as a unique journal and for his many contributions to orthopaedic surgery.
DePalma A. Loss of scapulohumeral motion (frozen shoulder). Ann Surg. 1952;135:193–204.DePalma AF. Origin and comparative anatomy of the pectoral limb. In: DePalma AF, ed. Surgery of the Shoulder. Philadelphia: JB Lippincott; 1950:1–14.DePalma AF. Recurrent dislocation of the shoulder joint. Ann Surg. 1950;132:1052–1065.DePalma AF. Diseases of the Knee: Management in Medicine and Surgery. Philadelphia, PA: JB Lippincott Company; 1954.DePalma AF. The Management of Fractures and Dislocations—An Atlas. Philadelphia: WB Saunders Company; 1959.DePalma AF. Surgical anatomy of the rotator cuff and the natural history of degenerative periarthritis. Surg Clin North Am. 1963;43:1507–1520.DePalma AF. A lifetime of devotion to the Janus of orthopedics. Bridging the gap between the clinic and laboratory. Clin Orthop Relat Res. 1991;265:146–169.DePalma AF, Rothman RH. The Intervertebral Disc. Philadelphia: WB Saunders Company; 1970.Derkash RS. History of the Association of Bone and Joint Surgeons. Clin Orthop Relat Res. 1997;337:306–309.Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J Bone Joint Surg Am. 1969;51:737–755.Larson CB. Rating scale for hip disabilities. Clin Orthop Relat Res. 1963;31:85–93.
PMCID: PMC2505210  PMID: 18264840
2.  The horror of wrong-site surgery continues: report of two cases in a regional trauma centre in Nigeria 
Wrong- site surgeries are iatrogenic errors encountered in the course of surgical patient management. Despite the ‘never do harm’ pledge in the ‘Hippocratic Oath’ drafted in 5th century BC, man is after all human, with this limitation manifesting in the physician’s art despite his best intention. Beyond the catastrophic consequences of wrong- site surgery on the patient and surgeon, and the opprobrium on the art of medicine, the incidents have come to be regarded as a quality-of-care indicator. Orthopaedic surgery is a specialty with a preponderance of this phenomenon and the attendant medico-legal issues relating to malpractice claims. Consequently the specialty had pioneered institutional initiatives at preventing these ‘friendly-fires’. Awareness and implementation of these initiatives however remain low in many parts of the world, hampered by a culture of denial and shame.
Case presentation
This report presents two cases of wrong-site surgery following trauma from road-traffic accident. The first case was a closed reduction of the ‘wrong’ dislocated hip in the trauma/emergency unit under the care of senior residents, while the second case was attempted wrong-site surgery on the right leg in a patient with fracture of the left tibia, in conjunction with bilateral femoral fracture and right radio-ulnar fracture; by an experienced Chief Consultant Orthopaedic Surgeon operating elective list. Both are orthopaedic cases, each with some trauma to both lower extremeties. Neither of the cases was formally mentioned anywhere in clinical discourse in the hospital, much less a formal report or audit.
There was no formal, institutionalized process to prevent wrong-site surgery in the health institution and this could have been largely responsible for these incidents. An open, mandatory process of reporting such incidents for relevant audit and awareness is necessary, as a mechanism for prevention rather than blame or punishment.
PMCID: PMC4312470  PMID: 25642288
Wrong- site surgery; Medical errors; Patient safety; “Universal protocol”; “WHO surgical safety checklist”
3.  Who Leaves the Hospital Against Medical Advice in the Orthopaedic Setting? 
Patients who leave the hospital against medical advice are at risk for readmission and for a variety of complications and are likely to consume more healthcare resources. However, little is known about which factors, if any, may be associated with self-discharge (discharge against medical advice) among orthopaedic inpatients.
We studied the frequency and factors associated with self-discharge in patients hospitalized for orthopaedic trauma and musculoskeletal infection.
Using discharge records from the Nationwide Inpatient Sample (2002–2011), we identified approximately 7,067,432 patient hospitalizations for orthopaedic trauma and 5,488,686 for musculoskeletal infection. We calculated the proportions of admissions that ended in self-discharge for both trauma and infection patients; then, we examined patient demographics, diagnoses, and hospital factors. Multivariable logistic regression models were constructed to determine independent predictors of self-discharge.
Approximately one in 333 (0.3%) patients hospitalized for an isolated fracture and one in 47 (2.1%) patients with musculoskeletal infection left against medical advice. Patient characteristics associated with self-discharge included age < 75 years (trauma: odds ratio [OR] 2.7, 95% confidence interval [CI] 2.5–2.8, p < 0.001; infection: OR 3.9, 95% CI 3.8–4.1, p < 0.001), male sex (trauma: OR 1.7, 95% CI 1.7–1.8, p < 0.001; infection: OR 1.4, 95% CI 1.3–1.4, p < 0.001), black race/ethnicity (trauma: OR 1.5, 95% CI 1.4–1.6, p < 0.001; infection: OR 1.1, 95% CI 1.1–1.1, p < 0.001), low household income (trauma: OR 1.5, 95% CI 1.4–1.5, p < 0.001; infection: OR 1.4, 95% CI 1.4–1.4, p < 0.001), nonprivate insurance (Medicare [trauma: OR 1.7, 95% CI 1.6–1.8, p < 0.001; infection: OR 2.5, 95% CI 2.4–2.5, p < 0.001] and Medicaid [trauma: OR 2.6, 95% CI 2.5–2.7, p < 0.001; infection: OR 3.2, 95% CI 3.2–3.3, p < 0.001]), and no insurance coverage (trauma: OR 3.0, 95% CI 2.9–3.1, p < 0.001; infection: OR 3.5, 95% CI 3.4–3.5, p < 0.001), less medical comorbidity (trauma: OR 0.94 per one-unit increase in the number of comorbidities, 95% CI 0.93–0.95, p < 0.001; infection: OR 0.88, 95% CI 0.87–0.88, p < 0.001), alcohol (trauma: OR, 2.3, 95% 2.2–2.4, p < 0.001; infection: OR 1.5, 95% CI 1.5–1.5, p < 0.001), opioid (trauma: OR 2.9, 95% CI 2.7–3.1, p < 0.001; infection: OR 4.4, 95% CI 4.3–4.4, p < 0.001) and nonopioid drug abuse (trauma: OR, 2.0, 95% CI 1.9–2.1, p < 0.001; infection: OR 2.8, 95% CI 2.8–2.9, p < 0.001), psychosis (trauma: OR 1.3, 95%CI 1.2–1.3, p < 0.001; infection: OR 1.3, 95% CI 1.3, 1.4, p < 0.001), and AIDS/HIV infection (trauma: OR 1.5, 95% CI 1.2–1.8, p < 0.001; infection: OR 1.3, 95% CI 1.3–1.4, p < 0.001). Patients with upper extremity fractures (OR 1.9, 95% CI 1.8–1.9, p < 0.001) or fractures of the neck and trunk (OR 2.1, 95% CI 2.0–2.2, p < 0.001) were more likely to leave against medical advice than patients with lower extremity fractures. Among infection hospitalizations, patients with cellulitis had the highest odds of self-discharge compared with carbuncle/furuncle (OR 1.3, 95% CI 1.2–1.5, p < 0.001). Self-discharges were more likely to occur at hospitals of larger size (trauma: OR 1.2, 95% CI 1.1–1.2, p < 0.001; infection: nonsignificant), located in urban settings (trauma: OR 1.3, 95% CI 1.2–1.4, p < 0.001; infection: OR 1.6, 95% CI 1.5–1.6, p < 0.001), and in the Northeast (trauma: OR 1.7, 95% CI 1.6–1.8, p < 0.001; infection: OR 1.6, 95% CI 1.6–1.6, p < 0.001) than at small, rural hospitals in the South.
Our data can be used to promptly identify orthopaedic inpatients at higher risk of self-discharge on admission and target interventions to optimize treatment adherence. Strategies to enhance physician communication skills among patients with low health literacy, improve cultural sensitivity, and proactively address substance abuse issues early during hospital admission may aid in preventing discharge dilemmas and merit additional study.
Level of Evidence
Level III, prognostic study. See the Instructions for Authors for complete description of levels of evidence.
PMCID: PMC4317430  PMID: 25187333
4.  Effects of Two Commercial Electronic Prescribing Systems on Prescribing Error Rates in Hospital In-Patients: A Before and After Study 
PLoS Medicine  2012;9(1):e1001164.
In a before-and-after study, Johanna Westbrook and colleagues evaluate the change in prescribing error rates after the introduction of two commercial electronic prescribing systems in two Australian hospitals.
Considerable investments are being made in commercial electronic prescribing systems (e-prescribing) in many countries. Few studies have measured or evaluated their effectiveness at reducing prescribing error rates, and interactions between system design and errors are not well understood, despite increasing concerns regarding new errors associated with system use. This study evaluated the effectiveness of two commercial e-prescribing systems in reducing prescribing error rates and their propensities for introducing new types of error.
Methods and Results
We conducted a before and after study involving medication chart audit of 3,291 admissions (1,923 at baseline and 1,368 post e-prescribing system) at two Australian teaching hospitals. In Hospital A, the Cerner Millennium e-prescribing system was implemented on one ward, and three wards, which did not receive the e-prescribing system, acted as controls. In Hospital B, the iSoft MedChart system was implemented on two wards and we compared before and after error rates. Procedural (e.g., unclear and incomplete prescribing orders) and clinical (e.g., wrong dose, wrong drug) errors were identified. Prescribing error rates per admission and per 100 patient days; rates of serious errors (5-point severity scale, those ≥3 were categorised as serious) by hospital and study period; and rates and categories of postintervention “system-related” errors (where system functionality or design contributed to the error) were calculated. Use of an e-prescribing system was associated with a statistically significant reduction in error rates in all three intervention wards (respectively reductions of 66.1% [95% CI 53.9%–78.3%]; 57.5% [33.8%–81.2%]; and 60.5% [48.5%–72.4%]). The use of the system resulted in a decline in errors at Hospital A from 6.25 per admission (95% CI 5.23–7.28) to 2.12 (95% CI 1.71–2.54; p<0.0001) and at Hospital B from 3.62 (95% CI 3.30–3.93) to 1.46 (95% CI 1.20–1.73; p<0.0001). This decrease was driven by a large reduction in unclear, illegal, and incomplete orders. The Hospital A control wards experienced no significant change (respectively −12.8% [95% CI −41.1% to 15.5%]; −11.3% [−40.1% to 17.5%]; −20.1% [−52.2% to 12.4%]). There was limited change in clinical error rates, but serious errors decreased by 44% (0.25 per admission to 0.14; p = 0.0002) across the intervention wards compared to the control wards (17% reduction; 0.30–0.25; p = 0.40). Both hospitals experienced system-related errors (0.73 and 0.51 per admission), which accounted for 35% of postsystem errors in the intervention wards; each system was associated with different types of system-related errors.
Implementation of these commercial e-prescribing systems resulted in statistically significant reductions in prescribing error rates. Reductions in clinical errors were limited in the absence of substantial decision support, but a statistically significant decline in serious errors was observed. System-related errors require close attention as they are frequent, but are potentially remediable by system redesign and user training. Limitations included a lack of control wards at Hospital B and an inability to randomize wards to the intervention.
Please see later in the article for the Editors' Summary
Editors' Summary
Medication errors—for example, prescribing the wrong drug or giving a drug by the wrong route—frequently occur in health care settings and are responsible for thousands of deaths every year. Until recently, medicines were prescribed and dispensed using systems based on hand-written scripts. In hospitals, for example, physicians wrote orders for medications directly onto a medication chart, which was then used by the nursing staff to give drugs to their patients. However, drugs are now increasingly being prescribed using electronic prescribing (e-prescribing) systems. With these systems, prescribers use a computer and order medications for their patients with the help of a drug information database and menu items, free text boxes, and prewritten orders for specific conditions (so-called passive decision support). The system reviews the patient's medication and known allergy list and alerts the physician to any potential problems, including drug interactions (active decision support). Then after the physician has responded to these alerts, the order is transmitted electronically to the pharmacy and/or the nursing staff who administer the prescription.
Why Was This Study Done?
By avoiding the need for physicians to write out prescriptions and by providing active and passive decision support, e-prescribing has the potential to reduce medication errors. But, even though many countries are investing in expensive commercial e-prescribing systems, few studies have evaluated the effects of these systems on prescribing error rates. Moreover, little is known about the interactions between system design and errors despite fears that e-prescribing might introduce new errors. In this study, the researchers analyze prescribing error rates in hospital in-patients before and after the implementation of two commercial e-prescribing systems.
What Did the Researchers Do and Find?
The researchers examined medication charts for procedural errors (unclear, incomplete, or illegal orders) and for clinical errors (for example, wrong drug or dose) at two Australian hospitals before and after the introduction of commercial e-prescribing systems. At Hospital A, the Cerner Millennium e-prescribing system was introduced on one ward; three other wards acted as controls. At Hospital B, the researchers compared the error rates on two wards before and after the introduction of the iSoft MedChart e-prescribing system. The introduction of an e-prescribing system was associated with a substantial reduction in error rates in the three intervention wards; error rates on the control wards did not change significantly during the study. At Hospital A, medication errors declined from 6.25 to 2.12 per admission after the introduction of e-prescribing whereas at Hospital B, they declined from 3.62 to 1.46 per admission. This reduction in error rates was mainly driven by a reduction in procedural error rates and there was only a limited change in overall clinical error rates. Notably, however, the rate of serious errors decreased across the intervention wards from 0.25 to 0.14 per admission (a 44% reduction), whereas the serious error rate only decreased by 17% in the control wards during the study. Finally, system-related errors (for example, selection of an inappropriate drug located on a drop-down menu next to a likely drug selection) accounted for 35% of errors in the intervention wards after the implementation of e-prescribing.
What Do These Findings Mean?
These findings show that the implementation of these two e-prescribing systems markedly reduced hospital in-patient prescribing error rates, mainly by reducing the number of incomplete, illegal, or unclear medication orders. The limited decision support built into both the e-prescribing systems used here may explain the limited reduction in clinical error rates but, importantly, both e-prescribing systems reduced serious medication errors. Finally, the high rate of system-related errors recorded in this study is worrying but is potentially remediable by system redesign and user training. Because this was a “real-world” study, it was not possible to choose the intervention wards randomly. Moreover, there was no control ward at Hospital B, and the wards included in the study had very different specialties. These and other aspects of the study design may limit the generalizability of these findings, which need to be confirmed and extended in additional studies. Even so, these findings provide persuasive evidence of the current and potential ability of commercial e-prescribing systems to reduce prescribing errors in hospital in-patients provided these systems are continually monitored and refined to improve their performance.
Additional Information
Please access these Web sites via the online version of this summary at
ClinfoWiki has pages on medication errors and on electronic prescribing (note: the Clinical Informatics Wiki is a free online resource that anyone can add to or edit)
Electronic prescribing in hospitals challenges and lessons learned describes the implementation of e-prescribing in UK hospitals; more information about e-prescribing in the UK is available on the NHS Connecting for Health Website
The Clinicians Guide to e-Prescribing provides up-to-date information about e-prescribing in the USA
Information about e-prescribing in Australia is also available
Information about electronic health records in Australia
PMCID: PMC3269428  PMID: 22303286
5.  Application of Circumferential Compression Device (Binder) in Pelvic Injuries: Room for Improvement 
The use of a noninvasive pelvic circumferential compression device (PCCD) to achieve pelvic stabilization by both decreasing pelvic volume and limiting inter-fragmentary motion has become commonplace, and is a well-established component of Advanced Trauma Life Support (ATLS) protocol in the treatment of pelvic ring injuries. The purpose of this study was to evaluate the following: 1) how consistently a PCCD was placed on patients who arrived at our hospital with unstable pelvic ring injuries; 2) if they were placed in a timely manner; and 3) if hemodynamic instability influenced their use.
We performed an institutional review board-approved retrospective study on 112 consecutive unstable pelvic ring injuries, managed over a two-year period at our Level I trauma center. Our hospital electronic medical records were used to review EMT, physician, nurses’, operative notes and radiographic images, to obtain information on the injury and PCCD application. The injuries were classified by an orthopaedic trauma surgeon and a senior orthopaedic resident. Proper application of a pelvic binder using a sheet is demonstrated.
Only 47% of unstable pelvic fractures received PCCD placement, despite being the standard of care according to ATLS. Lateral compression mechanism pelvic injuries received PCCDs in 33% of cases, while anterior posterior compression (APC) and vertical shear (VS) injuries had applications in 63% of cases. Most of these PCCD devices were applied after imaging (72%). Hemodynamic instability did not influence PCCD application.
PCCD placement was missed in many (37%) of APC and VS mechanism injuries, where their application could have been critical to providing stability. Furthermore, to provide rapid stability, pelvic circumferential compression devices should be applied after secondary examination, rather than after receiving imaging results. Better education on timing and technique of PCCD placement at our institution is required to improve treatment of pelvic ring injuries.
PMCID: PMC5102606  PMID: 27833687
6.  Simultaneous distal radius and lunate fractures: a lesson for an unwary eye 
BMJ Case Reports  2010;2010:bcr10.2009.2387.
Simultaneous distal radius and carpus fractures are uncommon. They can be missed because of a diffused clinical picture and an inexperienced clinician reviewing the patient and radiographs. A 64-year-old woman presented to the emergency department (ED) with a clinically deformed left wrist after a fall. Plain radiographs were interpreted as a distal radius intra-articular fracture with volar angulation, both by the ED physician and the first on call for trauma and orthopaedics (T&O). Review of the radiographs in the trauma meeting revealed the possibility of an additional undisplaced lunate fracture. A computed tomography scan confirmed the distal radius fracture in addition to an undisplaced fracture of the lunate. Because of the unstable nature of the distal radius fracture, open reduction and internal fixation was performed. As the lunate fracture was undisplaced, it was managed conservatively. The patient was discharged home the next day and has been doing well at follow-up.
PMCID: PMC3047489  PMID: 22485120
7.  CT-generated Radiographs in Obese Patients With Acetabular Fractures: Can They Be Used in Lieu of Plain Radiographs? 
Acetabular fracture diagnosis is traditionally made with AP and oblique pelvic plain radiographs. Obesity may impair diagnostic accuracy of plain radiographs. New CT reconstruction algorithms allow for simulated radiographs that may eliminate the adverse imaging effects of obesity.
In obese patients with acetabular fractures, we compared CT-generated and plain radiographs in terms of (1) ability to classify fracture type, (2) agreement in fracture classification, and (3) surgeon performance at different experience levels.
CT-generated and plain radiograph image sets were created for 16 obese (BMI > 35) patients with 17 acetabular fractures presenting from 2009 to 2011. Three orthopaedic trauma attending physicians, three senior residents, and three junior residents independently viewed these sets and recorded their diagnoses. These diagnoses were compared to the postoperative findings, which we defined as the gold standard for diagnosis. To assess intraobserver reliability, the same observers reviewed a rerandomized set 1 month later. We had 80% power to detect a 25% difference in the percentage of correctly classified fractures based on a post hoc sample size calculation and 80% power to detect a 0.10 difference in κ value based on both a priori and post hoc sample size calculations.
With the numbers available (153 observations in each image set, 51 for each of the three observer groups), we found no differences between CT-generated and plain radiographs, respectively, in terms of percentage of correct diagnoses for the observer groups (all observers: 54% versus 49%, p = 0.48; attendings: 61% versus 59%, p = 0.83; senior residents: 51% versus 53%, p = 0.84; and junior residents: 49% versus 35%, p = 0.16). Furthermore, agreement between CT-generated and plain radiographic fracture classifications was substantial (κ = 0.67). Nonetheless, the attending and senior resident groups performed better in correctly classifying the fracture than the junior residents when using plain radiographs (p = 0.01 and p = 0.049, respectively). Performance was not different when comparing the attendings to the senior resident and junior groups or comparing the senior residents to the junior residents using CT-generated radiographs (p = 0.32, p = 0.22, and p = 0.83, respectively).
CT-generated radiographs are as good as plain radiographs for experienced surgeons for classifying acetabular fractures in obese patients. CT-generated imaging may be valuable in both teaching and clinical settings, and it may spare the patient additional radiation exposure and discomfort.
Level of Evidence
Level II, diagnostic study. See the Instructions for Authors for a complete description of levels of evidence.
PMCID: PMC4182420  PMID: 24867453
8.  The Libyan civil conflict: selected case series of orthopaedic trauma managed in Malta in 2014 
The purpose of this series of cases was to analyse our management of orthopaedic trauma casualties in the Libyan civil war crisis in the European summer of 2014. We looked at both damage control orthopaedics and for case variety of war trauma at a civilian hospital. Due to our geographical proximity to Libya, Malta was the closest European tertiary referral centre. Having only one Level 1 trauma care hospital in our country, our Trauma and Orthopaedics department played a pivotal role in the management of Libyan battlefield injuries. Our aims were to assess acute outcomes and short term mortality of surgery within the perspective of a damage control orthopaedic strategy whereby aggressive wound management, early fixation using relative stability principles, antibiotic cover with adequate soft tissue cover are paramount. We also aim to describe the variety of war injuries we came across, with a goal for future improvement in regards to service providing.
Prospective collection of six interesting cases with severe limb and spinal injuries sustained in Libya during the Libyan civil war between June and November 2014.
We applied current trends in the treatment of war injuries, specifically in damage control orthopaedic strategy and converting to definitive treatment where permissible. The majority of our cases were classified as most severe (Type IIIB/C) according to the Gustilo-Anderson classification of open fractures. The injuries treated reflected the type of standard and improved weaponry available in modern warfare affecting both militants and civilians alike with increasing severity and extent of damage. Due to this fact, multidisciplinary team approach to patient centred care was utilised with an ultimate aim of swift recovery and early mobilisation. It also highlighted the difficulties and complex issues required on a hospital management level as a neighbouring country to war zone countries in transforming care of civil trauma to military trauma.
PMCID: PMC4654919  PMID: 26589677
Orthopaedics; Damage control surgery; Damage control orthopaedics (DCO); Improvised explosive device (IED); Blast injury; War trauma; Gustilo-Anderson; Indice de gravité simplifié 2 (IGS2)
9.  The TONK score: a tool for assessing quality in trauma and orthopaedic note-keeping 
SICOT-J  null;1:29.
Introduction: Medical case notes are the only lasting interpretation of a patient-physician interaction and are important for good quality patient care. Accurate, legible and contemporaneous note-keeping is important however it can be substandard. This can lead to errors in handover of patients and to medicolegal vulnerability. We present a comprehensive auditing tool for Trauma & Orthopaedics medical case notes and our experience in using it over the last 12 months.
Patients and Methods: The TONK score was developed from a pre-existing system with some additions for Trauma & Orthopaedic case notes, with the incorporation of a legibility scoring system. An initial audit was carried out evaluating the case notes for each team against the TONK score. In order to evaluate the reproducibility of this score, we employed the Cohen’s Kappa coefficient and noted substantial agreement. The individual team scores were analysed and the audit cycle completed four months later with the provision of feedback.
Results: Our first audit revealed a mean of 81 with a range from 70 to 90. Subsequent audits over the next two quarters revealed mean scores in excess of 90. Significant improvement has been noted in all areas of documentation and it has been decided to conduct this audit every six months in our department.
Conclusions: The TONK score is an easy, quick and reproducible tool, which aims to eliminate the weaknesses in Trauma & Orthopaedic medical note-keeping. It emphasises the medicolegal importance of accurate medical note-keeping to doctors at all levels of training.
PMCID: PMC4849244  PMID: 27163084
Quality; Note-keeping; Audit; Legibility
10.  London Trauma Conference 2015 
Avery, Pascale | Salm, Leopold | Bird, Flora | Hutchinson, Anja | Matthies, Ashley | Hudson, Anthony | Jarman, Heather | Nilsson, Maria Bergman | Konig, Tom | Tai, Nigel | Fevang, Espen | Hognestad, Børge | Abrahamsen, Håkon B. | Cheetham, Olivia V. | Thomas, Matthew J. C. | Rooney, Kieron D. | Murray, Josephine | Tunnicliff, Malcolm | Collinson, Joseph W. | Brown, Thomas | Pritchett, Christopher | Pritchett, Christopher S. A. | Jadav, Mark | Meredith, Gareth | Plumb, Jamie | Harris, Steve | Langford, Roger | Hunter, J. G. | Sage, A. | Madden, R. | Flamank, O. | Broadbent, B. | Marsh, S. | Lewis, H. | Daniels, E. | Roberts, N. | Hunter, J. G. | Sage, A. | Madden, R. | Flamank, O. | Broadbent, B. | Marsh, S. | Lewis, H. | Daniels, E. | Lin, N. | Roberts, N. | Bulford, Samuel | Houghton-Budd, Silas | Pearson, Sam | Clear-Hill, Megan | Menzies, David J. | Leonard, James P. | Keogh, Conor | Quinn, Ray | Hinds, John D. | Roberts, N. | Ashton-Cleary, D. | Jadav, M. | Mahmood, Ismail | El-Menyar, Ayman | Younis, Basil | Khalid, Ahmed | Nabir, Syed | Ahmed, Mohamed Nadeem | Al-Yahri, Omer | Al-Thani, Hassan | Young, Katie | Hendrickson, Susan A. | Phillips, Georgina | Gardiner, Matthew D. | Hettiaratchy, Shehan | Crossland, Alexandra Alice | Hudson, Anthony | Brassington, Nicholas C. | Hudson, Anthony | McWhirter, Emily | Reid, Bjørn O. | Rehn, Marius | Uleberg, Oddvar | Krüger, Andreas J. | Jennings, Cara | Kapadia, Yasmin | Bew, Duncan | Townsend, Jenny | Hurst, Tom P. | Foster, Elizabeth A. | Brown, Thomas B. | Collinson, Joseph | Pritchett, Christopher | Slade, Toby | Tønsager, Kristin | Rehn, Marius | G.Ringdal, Kjetil | J.Krüger, Andreas | Hesselfeldt, Rasmus | Wulffeld, Sandra | Sonne, Asger | Rasmussen, Lars S. | Steinmetz, Jacob | Renninson, Thomas J. | Thomson, Nadine | Pynn, Harvey | Hooper, Timothy J. | Hudson, Anthony | Dawson, Jacinta | Matthies, Ashley | Friberg, Morten Langfeldt | Rognås, Leif | Wills, Jessica F. G. | Hudson, Anthony | Turner, Conor D. A. | Rehn, Marius | Nunn, James | Erdogan, Mete | Green, Robert S. | Minor, Samuel | Erdogan, Mete | Hartlen, Kathy | Green, Robert S. | Bird, Ruth | Grupping, Rachael L. | Stacey, Amelia M. | Rehn, Marius | Lockey, David J. | Abiks, S. | Cutler, L. | Monaghan, K. | Al-Rais, A. | Hymers, C. | Bloomer, R. | Kapadia, Y. | Seidenfaden, Sophie-Charlott | Riddervold, Ingunn S. | Kirkegaard, Hans | Juul, Niels | Bøtker, Morten T. | Gao, Alice | Perkins, Zane | Grier, Gareth | Tzannes, Alex | Hudson-Peacock, Nathan J. | Otto, Quentin | Phillipson, Laurie | Thomas, Rik | Heyworth, Ainsley | Otto, Quentin | Hudson-Peacock, Nathan J. | Phillipson, Laurie | Heyworth, Ainsley | Ley, Erica | Banner, Daniel | Heyworth, Ainsley | Ley, Erica | Benson, Madeleine | Hudson-Peacock, Nathan | Stone, Tony | Ley, Erica | Rousson, Louise | Heyworth, Ainsley | Lineham, Beth A. | Lee, Matthew J. | Gough, Martin | Seligman, William H. | Thould, Hannah E. | Dinsmore, Andrew | Tan, Charlotte | Thompson, Julian | Eynon, C. Andy | Lockey, David J. | Wahlin, Rebecka M. Rubenson | Lindström, Veronica | Ponzer, Sari | Vicente, Veronica | Eligio, Pamela | Hudson, Anthony | Young, Robert | Amiras, Dimitri | Sinha, Ian
Table of contents
I1: Trauma, Pre-hospital and Cardiac Arrest Care 2015
Pascale Avery, Leopold Salm, Flora Bird
A1: Retrospective evaluation of HEMS ‘Direct to CT’ protocol
Anja Hutchinson, Ashley Matthies, Anthony Hudson, Heather Jarman
A2 Rush hour – Crush hour: temporal relationship of cyclist vs. HGV trauma admissions. A single site observational study
Maria Bergman Nilsson, Tom Konig, Nigel Tai
A3 Semiprone position endotracheal intubation during continuous cardiopulmonary resuscitation in drowned children with regurgitation: a case report and experimental manikin study
Espen Fevang, Børge Hognestad, Håkon B. Abrahamsen
A4 An audit of CO2 A-a gradient in non-trauma patients receiving pre-hospital anaesthesia
Olivia V Cheetham, Matthew JC Thomas, Kieron D Rooney
A5 Can the use of c-spine immobilisation collars be avoided in non-trauma patients presenting to the Emergency Department?
Josephine Murray, Malcolm Tunnicliff
A6 Curriculum mapping in ED point of care simulation
Joseph W Collinson, Thomas Brown, Christopher Pritchett
A7 Point of care multidisciplinary trauma team simulation & participant satisfaction in a geographically remote trauma unit in Cornwall
Christopher SA Pritchett, Mark Jadav, Gareth Meredith, Jamie Plumb, Steve Harris, Roger Langford
A8 Conservative management of head injury inpatients - the challenge of simplifying injury management in a non-neurosurgical hospital
JG Hunter, A Sage, R Madden, O Flamank, B Broadbent, S Marsh, H Lewis, E Daniels, N Roberts
A9 Improving the care of traumatic brain injury at non-neurosurgical hospitals: Introducing a head injury pathway and single place of care is associated with significant improvements in neurological observation
JG Hunter, A Sage, R Madden, O Flamank, B Broadbent, S Marsh, H Lewis, E Daniels, N Lin, N Roberts
A10 The experience of inter-disciplinary students undertaking cardiac arrest moulage training
Samuel Bulford, Silas Houghton-Budd, Sam Pearson, Megan Clear-Hill
A11 Impact brain apnoea – nine cases
David J Menzies, James P Leonard, Conor Keogh, Ray Quinn, John D Hinds
A12 Time well spent? Improving the performance improvement programme in a busy Trauma Unit
N Roberts, D Ashton-Cleary, M Jadav
A14 Clinical significant and outcome of pulmonary contusions in patients with blunt chest trauma
Ismail Mahmood, Ayman El-Menyar, Basil Younis, Ahmed Khalid, Syed Nabir, Mohamed Nadeem Ahmed, Omer Al-Yahri, Hassan Al-Thani
A15 Plastics operative workload in major trauma centres: a national prospective survey
Katie Young, Susan A. Hendrickson, Georgina Phillips, Matthew D. Gardiner, Shehan Hettiaratchy
A16 A survey to assess the accuracy of estimating height by pre-hospital clinicians: can we reliably predict those most at risk of serious injury?
Alexandra Alice Crossland, Anthony Hudson
A17 An audit of the cause, outcome and adherence to treatment Standard Operating Procedure (SOP) for all traumatic cardiac arrests at a Helicopter Emergency Medical Service over a 12-month period
Nicholas C Brassington, Anthony Hudson, Emily McWhirter
A18 Should we “stay-and-play? A study of patient physiology in Norwegian Helicopter Emergency Services
Bjørn O Reid, Marius Rehn, Oddvar Uleberg, Andreas J Krüger
A19 Training in resuscitative thoracotomy: have we cracked it? A survey of higher Emergency Medicine trainees in London
Cara Jennings, Yasmin Kapadia, Duncan Bew
A20 London’s Air Ambulance (LAA): 25-years of drownings in an urban environment
Jenny Townsend, Tom P Hurst, Elizabeth A Foster
A21 Live patients in trauma simulation – more than just simulation on a shoestring?
Thomas B Brown, Joseph Collinson, Christopher Pritchett, Toby Slade
A22 Collecting core data in pre-hospital critical care using a consensus based template
Kristin Tønsager, Marius Rehn, Kjetil G.Ringdal, Andreas J.Krüger
A23 Prehospital interventions before and after implementation of a physician staffed helicopter
Rasmus Hesselfeldt, Sandra Wulffeld, Asger Sonne, Lars S. Rasmussen, Jacob Steinmetz
A24 Duration of ventilation following prehospital drug assisted intubation; a retrospective review
Thomas J Renninson, Nadine Thomson, Harvey Pynn, Timothy J Hooper
A25 Non-haemorrhagic shock in trauma: a novel guideline for management in ED
Anthony Hudson, Jacinta Dawson, Ashley Matthies
A26 Patient-tailored triage decisions by anaesthetist-staffed pre-hospital critical care teams
Morten Langfeldt Friberg, Leif Rognås
A27 Anatomical accuracy and appropriate sizing of pre-hospital thoracostomies
Jessica FG Wills, Anthony Hudson
A28 Pre-hospital management of mass casualty civilian shootings
Conor DA Turner, Marius Rehn
A30 The prevalence of alcohol-related trauma recidivism: a systematic review
James Nunn, Mete Erdogan, Robert S. Green
A31 Development of a hospital-wide program for simulation-based training in trauma care and management
Samuel Minor, Mete Erdogan, Kathy Hartlen, Robert S. Green
A32 Out of Hospital Cardiac Arrests (OOHCA); lessons from Hollywood
Ruth Bird, Rachael L. Grupping
A33 Mechanism of injury as a predictor of severity of injury in road traffic collisions: a literature review
Amelia M. Stacey, Marius Rehn, David J. Lockey
A34 Lessons to be learned from prehospital airway intervention documentation? Are airway intervention documentation templates as successful in-hospital as prehospitally?
S. Abiks, L. Cutler, K. Monaghan, A. Al-Rais, C. Hymers, R. Bloomer, Y. Kapadia
A35 Novel biomarkers in prehospital management of traumatic brain injury (the PreTBI study protocol)
Sophie-Charlott Seidenfaden, Ingunn S. Riddervold, Hans Kirkegaard, Niels Juul, Morten T. Bøtker
A36 Hospital outcomes of traumatic railway incidents: a seven-year observational retrospective study of a major trauma centre
Alice Gao, Zane Perkins; Gareth Grier, Alex Tzannes
A37 Does taking a third crew member affect the on-scene time of HEMS jobs?
Nathan Hudson-Peacock, Quentin Otto, Laurie Phillipson, Rik Thomas, Ainsley Heyworth
A38 Does pre-hospital rapid sequence induction affect on-scene time of HEMS jobs?
Quentin Otto, Nathan Hudson-Peacock, Laurie Phillipson, Ainsley Heyworth, Erica Ley
A39 Code red: shock index as a prehospital indicator of massive haemorrhage
Daniel Banner, Ainsley Heyworth, Erica Ley
A40 Air ambulance tasking: how accurate are our current methods?
Madeleine Benson, Nathan Hudson-Peacock, Tony Stone, Erica Ley, Louise Rousson, Ainsley Heyworth
A41 Modern trauma burden in a district general hospital
Beth A Lineham, Matthew J Lee, Martin Gough
A42 Establishing a legal service for major trauma patients in two UK major trauma centres
William H Seligman, Hannah E Thould, Andrew Dinsmore, Charlotte Tan, Julian Thompson, C Andy Eynon, David J Lockey
A43 Prehospital assessment and care of patients – a study of the use of guidelines when assessing head trauma
Rebecka M Rubenson Wahlin, Veronica Lindström, Sari Ponzer, Veronica Vicente
A44 An audit of pre-hospital blood pressure management resulting from head injury
Pamela Eligio, Anthony Hudson
A45 The surgical contribution of surface shading volumetric rendering techniques in rib fracture management
Robert Young, Dimitri Amiras, Ian Sinha
PMCID: PMC4928155  PMID: 27357386
11.  Caregiver- and Patient-Directed Interventions for Dementia 
Executive Summary
In early August 2007, the Medical Advisory Secretariat began work on the Aging in the Community project, an evidence-based review of the literature surrounding healthy aging in the community. The Health System Strategy Division at the Ministry of Health and Long-Term Care subsequently asked the secretariat to provide an evidentiary platform for the ministry’s newly released Aging at Home Strategy.
After a broad literature review and consultation with experts, the secretariat identified 4 key areas that strongly predict an elderly person’s transition from independent community living to a long-term care home. Evidence-based analyses have been prepared for each of these 4 areas: falls and fall-related injuries, urinary incontinence, dementia, and social isolation. For the first area, falls and fall-related injuries, an economic model is described in a separate report.
Please visit the Medical Advisory Secretariat Web site,, to review these titles within the Aging in the Community series.
Aging in the Community: Summary of Evidence-Based Analyses
Prevention of Falls and Fall-Related Injuries in Community-Dwelling Seniors: An Evidence-Based Analysis
Behavioural Interventions for Urinary Incontinence in Community-Dwelling Seniors: An Evidence-Based Analysis
Caregiver- and Patient-Directed Interventions for Dementia: An Evidence-Based Analysis
Social Isolation in Community-Dwelling Seniors: An Evidence-Based Analysis
The Falls/Fractures Economic Model in Ontario Residents Aged 65 Years and Over (FEMOR)
This report features the evidence-based analysis on caregiver- and patient-directed interventions for dementia and is broken down into 4 sections:
Caregiver-Directed Interventions for Dementia
Patient-Directed Interventions for Dementia
Economic Analysis of Caregiver- and Patient-Directed Interventions for Dementia
Caregiver-Directed Interventions for Dementia
To identify interventions that may be effective in supporting the well-being of unpaid caregivers of seniors with dementia living in the community.
Clinical Need: Target Population and Condition
Dementia is a progressive and largely irreversible syndrome that is characterized by a loss of cognitive function severe enough to impact social or occupational functioning. The components of cognitive function affected include memory and learning, attention, concentration and orientation, problem-solving, calculation, language, and geographic orientation. Dementia was identified as one of the key predictors in a senior’s transition from independent community living to admission to a long-term care (LTC) home, in that approximately 90% of individuals diagnosed with dementia will be institutionalized before death. In addition, cognitive decline linked to dementia is one of the most commonly cited reasons for institutionalization.
Prevalence estimates of dementia in the Ontario population have largely been extrapolated from the Canadian Study of Health and Aging conducted in 1991. Based on these estimates, it is projected that there will be approximately 165,000 dementia cases in Ontario in the year 2008, and by 2010 the number of cases will increase by nearly 17% over 2005 levels. By 2020 the number of cases is expected to increase by nearly 55%, due to a rise in the number of people in the age categories with the highest prevalence (85+). With the increase in the aging population, dementia will continue to have a significant economic impact on the Canadian health care system. In 1991, the total costs associated with dementia in Canada were $3.9 billion (Cdn) with $2.18 billion coming from LTC.
Caregivers play a crucial role in the management of individuals with dementia because of the high level of dependency and morbidity associated with the condition. It has been documented that a greater demand is faced by dementia caregivers compared with caregivers of persons with other chronic diseases. The increased burden of caregiving contributes to a host of chronic health problems seen among many informal caregivers of persons with dementia. Much of this burden results from managing the behavioural and psychological symptoms of dementia (BPSD), which have been established as a predictor of institutionalization for elderly patients with dementia.
It is recognized that for some patients with dementia, an LTC facility can provide the most appropriate care; however, many patients move into LTC unnecessarily. For individuals with dementia to remain in the community longer, caregivers require many types of formal and informal support services to alleviate the stress of caregiving. These include both respite care and psychosocial interventions. Psychosocial interventions encompass a broad range of interventions such as psychoeducational interventions, counseling, supportive therapy, and behavioural interventions.
Assuming that 50% of persons with dementia live in the community, a conservative estimate of the number of informal caregivers in Ontario is 82,500. Accounting for the fact that 29% of people with dementia live alone, this leaves a remaining estimate of 58,575 Ontarians providing care for a person with dementia with whom they reside.
Description of Interventions
The 2 main categories of caregiver-directed interventions examined in this review are respite care and psychosocial interventions. Respite care is defined as a break or relief for the caregiver. In most cases, respite is provided in the home, through day programs, or at institutions (usually 30 days or less). Depending on a caregiver’s needs, respite services will vary in delivery and duration. Respite care is carried out by a variety of individuals, including paid staff, volunteers, family, or friends.
Psychosocial interventions encompass a broad range of interventions and have been classified in various ways in the literature. This review will examine educational, behavioural, dementia-specific, supportive, and coping interventions. The analysis focuses on behavioural interventions, that is, those designed to help the caregiver manage BPSD. As described earlier, BPSD are one of the most challenging aspects of caring for a senior with dementia, causing an increase in caregiver burden. The analysis also examines multicomponent interventions, which include at least 2 of the above-mentioned interventions.
Methods of Evidence-Based Analysis
A comprehensive search strategy was used to identify systematic reviews and randomized controlled trials (RCTs) that examined the effectiveness of interventions for caregivers of dementia patients.
Section 2.1
Are respite care services effective in supporting the well-being of unpaid caregivers of seniors with dementia in the community?
Do respite care services impact on rates of institutionalization of these seniors?
Section 2.2
Which psychosocial interventions are effective in supporting the well-being of unpaid caregivers of seniors with dementia in the community?
Which interventions reduce the risk for institutionalization of seniors with dementia?
Outcomes of Interest
any quantitative measure of caregiver psychological health, including caregiver burden, depression, quality of life, well-being, strain, mastery (taking control of one’s situation), reactivity to behaviour problems, etc.;
rate of institutionalization; and
Assessment of Quality of Evidence
The quality of the evidence was assessed as High, Moderate, Low, or Very low according to the GRADE methodology and GRADE Working Group. As per GRADE the following definitions apply:
Summary of Findings
Conclusions in Table 1 are drawn from Sections 2.1 and 2.2 of the report.
Summary of Conclusions on Caregiver-Directed Interventions
There is limited evidence from RCTs that respite care is effective in improving outcomes for those caring for seniors with dementia.
There is considerable qualitative evidence of the perceived benefits of respite care.
Respite care is known as one of the key formal support services for alleviating caregiver burden in those caring for dementia patients.
Respite care services need to be tailored to individual caregiver needs as there are vast differences among caregivers and patients with dementia (severity, type of dementia, amount of informal/formal support available, housing situation, etc.)
There is moderate- to high-quality evidence that individual behavioural interventions (≥ 6 sessions), directed towards the caregiver (or combined with the patient) are effective in improving psychological health in dementia caregivers.
There is moderate- to high-quality evidence that multicomponent interventions improve caregiver psychosocial health and may affect rates of institutionalization of dementia patients.
RCT indicates randomized controlled trial.
Patient-Directed Interventions for Dementia
The section on patient-directed interventions for dementia is broken down into 4 subsections with the following questions:
3.1 Physical Exercise for Seniors with Dementia – Secondary Prevention
What is the effectiveness of physical exercise for the improvement or maintenance of basic activities of daily living (ADLs), such as eating, bathing, toileting, and functional ability, in seniors with mild to moderate dementia?
3.2 Nonpharmacologic and Nonexercise Interventions to Improve Cognitive Functioning in Seniors With Dementia – Secondary Prevention
What is the effectiveness of nonpharmacologic interventions to improve cognitive functioning in seniors with mild to moderate dementia?
3.3 Physical Exercise for Delaying the Onset of Dementia – Primary Prevention
Can exercise decrease the risk of subsequent cognitive decline/dementia?
3.4 Cognitive Interventions for Delaying the Onset of Dementia – Primary Prevention
Does cognitive training decrease the risk of cognitive impairment, deterioration in the performance of basic ADLs or instrumental activities of daily living (IADLs),1 or incidence of dementia in seniors with good cognitive and physical functioning?
Clinical Need: Target Population and Condition
Secondary Prevention2
Physical deterioration is linked to dementia. This is thought to be due to reduced muscle mass leading to decreased activity levels and muscle atrophy, increasing the potential for unsafe mobility while performing basic ADLs such as eating, bathing, toileting, and functional ability.
Improved physical conditioning for seniors with dementia may extend their independent mobility and maintain performance of ADL.
Nonpharmacologic and Nonexercise Interventions
Cognitive impairments, including memory problems, are a defining feature of dementia. These impairments can lead to anxiety, depression, and withdrawal from activities. The impact of these cognitive problems on daily activities increases pressure on caregivers.
Cognitive interventions aim to improve these impairments in people with mild to moderate dementia.
Primary Prevention3
Various vascular risk factors have been found to contribute to the development of dementia (e.g., hypertension, hypercholesterolemia, diabetes, overweight).
Physical exercise is important in promoting overall and vascular health. However, it is unclear whether physical exercise can decrease the risk of cognitive decline/dementia.
Nonpharmacologic and Nonexercise Interventions
Having more years of education (i.e., a higher cognitive reserve) is associated with a lower prevalence of dementia in crossectional population-based studies and a lower incidence of dementia in cohorts followed longitudinally. However, it is unclear whether cognitive training can increase cognitive reserve or decrease the risk of cognitive impairment, prevent or delay deterioration in the performance of ADLs or IADLs or reduce the incidence of dementia.
Description of Interventions
Physical exercise and nonpharmacologic/nonexercise interventions (e.g., cognitive training) for the primary and secondary prevention of dementia are assessed in this review.
Evidence-Based Analysis Methods
A comprehensive search strategy was used to identify systematic reviews and RCTs that examined the effectiveness, safety and cost effectiveness of exercise and cognitive interventions for the primary and secondary prevention of dementia.
Section 3.1: What is the effectiveness of physical exercise for the improvement or maintenance of ADLs in seniors with mild to moderate dementia?
Section 3.2: What is the effectiveness of nonpharmacologic/nonexercise interventions to improve cognitive functioning in seniors with mild to moderate dementia?
Section 3.3: Can exercise decrease the risk of subsequent cognitive decline/dementia?
Section 3.4: Does cognitive training decrease the risk of cognitive impairment, prevent or delay deterioration in the performance of ADLs or IADLs, or reduce the incidence of dementia in seniors with good cognitive and physical functioning?
Assessment of Quality of Evidence
The quality of the evidence was assessed as High, Moderate, Low, or Very low according to the GRADE methodology. As per GRADE the following definitions apply:
Summary of Findings
Table 2 summarizes the conclusions from Sections 3.1 through 3.4.
Summary of Conclusions on Patient-Directed Interventions*
Previous systematic review indicated that “cognitive training” is not effective in patients with dementia.
A recent RCT suggests that CST (up to 7 weeks) is effective for improving cognitive function and quality of life in patients with dementia.
Regular leisure time physical activity in midlife is associated with a reduced risk of dementia in later life (mean follow-up 21 years).
Regular physical activity in seniors is associated with a reduced risk of cognitive decline (mean follow-up 2 years).
Regular physical activity in seniors is associated with a reduced risk of dementia (mean follow-up 6–7 years).
Evidence that cognitive training for specific functions (memory, reasoning, and speed of processing) produces improvements in these specific domains.
Limited inconclusive evidence that cognitive training can offset deterioration in the performance of self-reported IADL scores and performance assessments.
1° indicates primary; 2°, secondary; CST, cognitive stimulation therapy; IADL, instrumental activities of daily living; RCT, randomized controlled trial.
Benefit/Risk Analysis
As per the GRADE Working Group, the overall recommendations consider 4 main factors:
the trade-offs, taking into account the estimated size of the effect for the main outcome, the confidence limits around those estimates, and the relative value placed on the outcome;
the quality of the evidence;
translation of the evidence into practice in a specific setting, taking into consideration important factors that could be expected to modify the size of the expected effects such as proximity to a hospital or availability of necessary expertise; and
uncertainty about the baseline risk for the population of interest.
The GRADE Working Group also recommends that incremental costs of health care alternatives should be considered explicitly alongside the expected health benefits and harms. Recommendations rely on judgments about the value of the incremental health benefits in relation to the incremental costs. The last column in Table 3 reflects the overall trade-off between benefits and harms (adverse events) and incorporates any risk/uncertainty (cost-effectiveness).
Overall Summary Statement of the Benefit and Risk for Patient-Directed Interventions*
Economic Analysis
Budget Impact Analysis of Effective Interventions for Dementia
Caregiver-directed behavioural techniques and patient-directed exercise programs were found to be effective when assessing mild to moderate dementia outcomes in seniors living in the community. Therefore, an annual budget impact was calculated based on eligible seniors in the community with mild and moderate dementia and their respective caregivers who were willing to participate in interventional home sessions. Table 4 describes the annual budget impact for these interventions.
Annual Budget Impact (2008 Canadian Dollars)
Assumed 7% prevalence of dementia aged 65+ in Ontario.
Assumed 8 weekly sessions plus 4 monthly phone calls.
Assumed 12 weekly sessions plus biweekly sessions thereafter (total of 20).
Assumed 2 sessions per week for first 5 weeks. Assumed 90% of seniors in the community with dementia have mild to moderate disease. Assumed 4.5% of seniors 65+ are in long-term care, and the remainder are in the community. Assumed a rate of participation of 60% for both patients and caregivers and of 41% for patient-directed exercise. Assumed 100% compliance since intervention administered at the home. Cost for trained staff from Ministry of Health and Long-Term Care data source. Assumed cost of personal support worker to be equivalent to in-home support. Cost for recreation therapist from Alberta government Website.
Note: This budget impact analysis was calculated for the first year after introducing the interventions from the Ministry of Health and Long-Term Care perspective using prevalence data only. Prevalence estimates are for seniors in the community with mild to moderate dementia and their respective caregivers who are willing to participate in an interventional session administered at the home setting. Incidence and mortality rates were not factored in. Current expenditures in the province are unknown and therefore were not included in the analysis. Numbers may change based on population trends, rate of intervention uptake, trends in current programs in place in the province, and assumptions on costs. The number of patients was based on patients likely to access these interventions in Ontario based on assumptions stated below from the literature. An expert panel confirmed resource consumption.
PMCID: PMC3377513  PMID: 23074509
12.  A Survey of Post-Intake Orthopaedic Trauma Meetings in England 
The structure of trauma meetings has been noted to vary considerably throughout our region. The aim of this study was to assess current practice of trauma meetings on a national level and to propose a structure on the basis of the survey.
A telephone survey of 120 hospitals in England was performed with a 100% response rate. The on-call duty orthopaedic surgeon at each hospital was contacted and questioned regarding trauma meetings held at that hospital. Details obtained included the frequency of meetings, the presence of medical staff and staff from other disciplines, review of radiographs and educational value.
In total, 107 (89.2%) hospitals conducted regular trauma meetings with a mean duration of 36 min (range, 15–120 min). Teaching of junior medical staff occurred at 89 (83.2%) meetings. Postoperative radiographs were reviewed at 80 (74.8%) hospitals. A radiologist attended in 5 (4.7%) of meetings. The median number of consultants present was 3 (range, 1–10). Other attendees included trauma co-ordinators (34.6%), physiotherapists (30.8%), theatre staff (23.4%), nursing staff (20.6%) and anaesthetists (15.9%).
Trauma meetings assist with the organisation of trauma lists, the review of results and have a valuable educational component. However, in busier orthopaedic units, additional meetings for teaching purposes may be necessary as an adjunct to routine daily trauma meetings.
PMCID: PMC1963542  PMID: 17323531
Trauma meetings; Survey; Telephone survey
13.  Immediate Weight-Bearing after Ankle Fracture Fixation 
Advances in Orthopedics  2015;2015:491976.
We believe that a certain subset of surgical ankle fracture patients can be made weight-bearing as tolerated immediately following surgery. Immediate weight-bearing as tolerated (IWBAT) allows patients to return to ambulation and activities of daily living faster and may facilitate rehabilitation. A prospectively gathered orthopaedic trauma database at a Level 1 trauma center was reviewed retrospectively to identify patients who had ORIF after unstable ankle injuries treated by the senior author. Patients were excluded if they were not IWBAT based on specific criteria or if they did meet followup requirement. Only 1/26 patients was noted to have loss of fixation. This was found at the 6-week followup and was attributed to a missed syndesmotic injury. At 2-week followup, 2 patients had peri-incisional erythema that resolved with a short course of oral antibiotics. At 6-week followup, 20 patients were wearing normal shoes and 6 patients continued to wear the CAM Boot for comfort. To conclude, IWBAT in a certain subset of patients with stable osteosynthesis following an ankle fracture could potentially be a safe alternative to a period of protected weight-bearing.
PMCID: PMC4345246  PMID: 25785201
14.  Derivation and Validation of Two Decision Instruments for Selective Chest CT in Blunt Trauma: A Multicenter Prospective Observational Study (NEXUS Chest CT) 
PLoS Medicine  2015;12(10):e1001883.
Unnecessary diagnostic imaging leads to higher costs, longer emergency department stays, and increased patient exposure to ionizing radiation. We sought to prospectively derive and validate two decision instruments (DIs) for selective chest computed tomography (CT) in adult blunt trauma patients.
Methods and Findings
From September 2011 to May 2014, we prospectively enrolled blunt trauma patients over 14 y of age presenting to eight US, urban level 1 trauma centers in this observational study. During the derivation phase, physicians recorded the presence or absence of 14 clinical criteria before viewing chest imaging results. We determined injury outcomes by CT radiology readings and categorized injuries as major or minor according to an expert-panel-derived clinical classification scheme. We then employed recursive partitioning to derive two DIs: Chest CT-All maximized sensitivity for all injuries, and Chest CT-Major maximized sensitivity for only major thoracic injuries (while increasing specificity). In the validation phase, we employed similar methodology to prospectively test the performance of both DIs.
We enrolled 11,477 patients—6,002 patients in the derivation phase and 5,475 patients in the validation phase. The derived Chest CT-All DI consisted of (1) abnormal chest X-ray, (2) rapid deceleration mechanism, (3) distracting injury, (4) chest wall tenderness, (5) sternal tenderness, (6) thoracic spine tenderness, and (7) scapular tenderness. The Chest CT-Major DI had the same criteria without rapid deceleration mechanism. In the validation phase, Chest CT-All had a sensitivity of 99.2% (95% CI 95.4%–100%), a specificity of 20.8% (95% CI 19.2%–22.4%), and a negative predictive value (NPV) of 99.8% (95% CI 98.9%–100%) for major injury, and a sensitivity of 95.4% (95% CI 93.6%–96.9%), a specificity of 25.5% (95% CI 23.5%–27.5%), and a NPV of 93.9% (95% CI 91.5%–95.8%) for either major or minor injury. Chest CT-Major had a sensitivity of 99.2% (95% CI 95.4%–100%), a specificity of 31.7% (95% CI 29.9%–33.5%), and a NPV of 99.9% (95% CI 99.3%–100%) for major injury and a sensitivity of 90.7% (95% CI 88.3%–92.8%), a specificity of 37.9% (95% CI 35.8%–40.1%), and a NPV of 91.8% (95% CI 89.7%–93.6%) for either major or minor injury. Regarding the limitations of our work, some clinicians may disagree with our injury classification and sensitivity thresholds for injury detection.
We prospectively derived and validated two DIs (Chest CT-All and Chest CT-Major) that identify blunt trauma patients with clinically significant thoracic injuries with high sensitivity, allowing for a safe reduction of approximately 25%–37% of unnecessary chest CTs. Trauma evaluation protocols that incorporate these DIs may decrease unnecessary costs and radiation exposure in the disproportionately young trauma population.
In this multicenter prospective observational study, Robert Rodriguez and colleagues derive and validate two decision instruments for identifying which blunt trauma patients should receive chest CT and which can avoid unnecessary imaging.
Editors' Summary
Trauma—a serious injury to the body caused by violence or an accident—is a major global health problem. Every year, events that include traffic collisions, falls, and burns cause injuries that kill more than 5 million people (9% of annual global deaths). Road traffic accidents alone cause about 1.24 million deaths per year. In many countries, including the US, trauma is the number one killer of individuals aged 1–46 years. Chest injuries—damage to the chest wall such, as rib fractures, or damage to the lungs, heart, airways, or major blood vessels within the chest—are responsible for a quarter of trauma deaths. Chest injuries can be penetrating or blunt. Penetrating injuries (for example, stabbings) are generally easy to diagnose and usually require surgery. Blunt injuries, which are often the result of falls or road accidents, can often be managed with relatively simple interventions such as mechanical ventilation but can be hard to diagnose.
Why Was This Study Done?
Computed tomography (CT) is often used to evaluate patients with blunt trauma. This imaging procedure uses special X-ray equipment and computer programs to create two-dimensional and three-dimensional pictures of the organs, bones, and other tissues of the body. CT is good at providing information about internal injuries, and many trauma centers now routinely examine victims of major trauma using head-to-pelvis CT. However, chest CT exposes patients to radiation doses that may increase their risk of cancer. Moreover, chest CT is expensive and does not always provide much additional information if completed after a normal chest X-ray. To reduce the costs and radiation risks of unnecessary CT imaging after blunt trauma, in this prospective observational study, the researchers develop and validate two clinical decision instruments that identify patients with blunt chest injuries, thereby allowing clinicians to forego CT in patients who do not meet the decision instrument criteria for blunt injuries.
What Did the Researchers Do and Find?
The researchers had clinicians record the presence or absence of 14 candidate clinical criteria in 6,002 patients aged over 14 years attending eight US trauma centers with blunt trauma before viewing chest CT results and categorizing the injuries seen as major or minor using a preset classification scheme. They then derived two clinical decision instruments from these data using a statistical method called recursive partitioning. The Chest CT-All decision instrument, which maximized sensitivity (the ability to correctly identify people with a condition) for either major and minor chest injuries, consisted of seven clinical criteria including an abnormal x-ray, rapid deceleration mechanism (trauma caused by, for example, a road collision occurring at more than 40 mph), and bone tenderness (pain that occurs when an area is touched) in the chest. The Chest CT-Major instrument, which maximized sensitivity for only major chest injuries, consisted of the same criteria without rapid deceleration mechanism. Applied to 5,475 additional patients who presented with blunt trauma, the Chest CT-All instrument correctly identified 95.4% of patients with a major or minor blunt chest injury as having an injury (a sensitivity of 95.4%) and 25.5% of patients without a major or minor injury as not having an injury (a specificity of 25.5%); the instrument had a negative predictive value (NPV) of 93.9% (a patient judged injury-free using the instrument had a 93.9% probability of being injury-free). The Chest CT-Major instrument had a sensitivity of 99.2%, specificity of 31.7%, and NPV of 99.9% for major injuries.
What Do These Findings Mean?
These findings describe two decision instruments that detect clinically important blunt chest injuries with high sensitivity. Because the use of these instruments allows clinicians to identify virtually everyone who has this type of injury, clinicians can forego CT in patients who do not exhibit any of the decision instrument criteria for blunt chest injury. That is, clinicians can safely use physical examination and history findings, instead of imaging, to rule out blunt chest injury in many patients attending a trauma center. Limitations of this study include the criteria used to classify injuries as minor or major. Moreover, these decision instruments should be used to augment rather than replace clinical judgment and should not be used to evaluate patients younger than 15 years old. Importantly, however, use of these decision instruments could reduce the number of unnecessary chest CTs undertaken in trauma centers by up to a third, thus reducing costs and radiation exposure in people with trauma.
Additional Information.
This list of resources contains links that can be accessed when viewing the PDF on a device or via the online version of the article at
This study is further discussed in a PLOS Medicine Perspective by Emmanuel Lagarde
The World Health Organization provides information in several languages about injuries around the world; its Guidelines for Essential Trauma Care seeks to set achievable standards for trauma treatment services that could realistically be made available to almost every injured person in the world
The US National Institute of General Medical Sciences has a factsheet on trauma
The National Trauma Institute, a not-for-profit organization that supports research on trauma, provides US trauma statistics, trauma survivor stories, and links to other organizations in the US that provide information on trauma
Wikipedia has pages on major trauma, chest injury, and computed tomography (note that Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
MedlinePlus provides links to additional information about trauma and about chest injuries and disorders (in English and Spanish)
PMCID: PMC4595216  PMID: 26440607
15.  Delays in orthopaedic trauma treatment: setting standards for the time interval between admission and operation. 
Delay in operating on trauma patients leads to increased morbidity, mortality, length of hospital stay and overall cost. The urgency of operative intervention depends on the injury sustained. There are no published guidelines on what constitutes a reasonable delay between admission and operation. As part of the clinical governance in our unit, an audit was undertaken to examine the structure and process of trauma operating. Patients were allocated to groups defined by the Bath Orthopaedic Department, according to urgency of need for surgery. Group A: patients (for example, open fractures and dislocations) should have definitive treatment within 6 h of admission. Group B: patients (for example, hip fractures, long bone injuries and ankle fractures) should have operations on the day that they are presented to the consultant trauma meeting, or on the day that they are declared fit/ready for theatre. Group C: patients (for example, tendon injuries, simple hand fractures) should have operations within 5 days of presentation to the trauma meeting. Over 3 months, there were 401 acute orthopaedic admissions requiring surgery (61 group A, 277 group B, 63 group C). 78% of group A patients, 58% of group B patients and 86% of group C patients were operated on within the target times. In total, 137 out of 401 operations (34%) missed the targets set. 119 of these (87%) were delayed due to lack of available operating time. This was despite the fact that 59 operations (15% of total) were done on lists normally used for elective operating. Most of the other delays were due to the need for an appropriately experienced surgeon to be available. If these targets are to be achieved for the majority of patients, the trauma theatre must become more efficient, or more flexible time must be made available during evenings or weekends to clear the backlog of trauma operations.
PMCID: PMC2503628  PMID: 11041030
16.  Role of the trauma-room chest x-ray film in assessing the patient with severe blunt traumatic injury 
Canadian Journal of Surgery  1996;39(1):36-41.
To examine the accuracy of standard trauma-room chest x-ray films in assessing blunt abdominal trauma and to determine the significance of missed injuries under these circumstances.
A retrospective review.
A regional trauma unit in a tertiary-care institution.
Multiply injured trauma patients admitted between January 1988 and December 1990 who died within 24 hours of injury and in whom an autopsy was done.
Standard radiography of the chest.
Main Outcome Measures
Chest injuries diagnosed and recorded by the trauma room team from standard anteroposterior x-ray films compared with the findings at autopsy and with review of the films by a staff radiologist initially having no knowledge of the injuries and later, if injuries remained undetected, having knowledge of the autopsy findings.
Thirty-seven patients met the study criteria, and their cases were reviewed. In 11 cases, significant injuries were noted at autopsy and not by the trauma-room team, and in 7 cases these injuries were also missed by the reviewing radiologist. Injuries missed by the team were: multiple rib fractures (11 cases), sternal fractures (3 cases), diaphragmatic tear (2 cases) and intimal aortic tear (1 case). In five cases, chest tubes were not inserted despite the presence (undiagnosed) of multiple rib fractures and need for intubation and positive-pressure ventilation.
Significant blunt abdominal trauma, potentially requiring operative management or chest-tube insertion, may be missed on the initial anteroposterior chest x-ray film. Caution must therefore be exercised in interpreting these films in the trauma resuscitation room.
PMCID: PMC3895124  PMID: 8599789
17.  Stress-Induced Hyperglycemia as a Risk Factor for Surgical-Site Infection in Non-diabetic Orthopaedic Trauma Patients Admitted to the Intensive Care Unit 
Journal of orthopaedic trauma  2013;27(1):16-21.
To evaluate the association between stress-induced hyperglycemia and infectious complications in non-diabetic orthopaedic trauma patients admitted to the Intensive Care Unit (ICU).
Retrospective review.
Academic Level-1 Trauma Center.
One hundred and eighty-seven consecutive trauma patients with isolated orthopaedic injuries.
Blood glucose values during initial hospitalization were evaluated. The admission blood glucose (BG) and Hyperglycemic Index (HGI) were determined for each patient.
Main Outcome Measures
Perioperative infectious complications: pneumonia, urinary tract infection (UTI), surgical-site infection (SSI), sepsis.
An average of 21.5 BG values was obtained for each patient. Mean ICU and hospital length of stay was 4.0±4.9 and 10.0±8.1 days, respectively. Infections were recorded in 43/187 patients (23.0%) and SSI’s specifically documented in 16 patients (8.6%). Open fractures were not associated with SSI (8/83, 9.6% vs. 8/104, 7.7%). There was no difference in admission BG or HGI and infection. However, there was a significant difference in HGI when considering SSI alone (2.1±1.7 vs. 1.2±1.1). Patients with an SSI received a greater amount of blood transfusions (14.9±12.1 vs. 4.9±7.6). No patient was diagnosed with a separate infection (i.e. pneumonia, UTI, bacteremia) prior to SSI. There was no significant difference in Injury Severity Score among patients with an SSI (11.1±4.0 vs. 9.6±3.0). Multivariable regression testing with HGI as a continuous variable demonstrated a significant relationship (OR: 1.8, 95% CI: 1.3–2.5) with SSI after adjusting for blood transfusions (OR: 1.1, 95% CI: 1.1–1.2).
Stress-induced hyperglycemia demonstrated a significant independent association with SSI’s in non-diabetic orthopaedic trauma patients who were admitted to the ICU.
PMCID: PMC3507335  PMID: 22588532
hyperglycemia; orthopaedic trauma; surgical site infection; non-diabetic; intensive care unit
18.  Child Abuse: The Role of the Orthopaedic Surgeon in Nonaccidental Trauma 
Child abuse presents in many different forms: physical, sexual, psychological, and neglect. The orthopaedic surgeon is involved mostly with physical abuse but should be aware of the other forms. There is limited training regarding child abuse, and the documentation is poor when a patient is at risk for abuse. There is a considerable risk to children when abuse is not recognized.
In this review, we (1) define abuse, (2) describe the incidence and demographic characteristics of abuse, (3) describe the orthopaedic manifestations of abuse, and (4) define the orthopaedic surgeon’s role in cases of abuse.
We performed a PubMed literature review and a search of the Department of Health and Human Services Web site. The Pediatric Orthopaedic Surgery of North America trauma symposium was referenced and expanded to create this review.
Recognition and awareness of child abuse are the primary tasks of the orthopaedic surgeon. Skin trauma is more common than fractures, yet fractures are the most common radiographic finding. Patients with fractures who are younger than 3 years, particularly those younger than 1 year, should be evaluated for abuse. No fracture type or location is pathognomonic. Management in the majority of fracture cases resulting from abuse is nonoperative casting or splinting.
The role of the orthopaedic surgeon in suspected cases of child abuse includes (1) obtaining a good history and making a thorough physical examination; (2) obtaining the appropriate radiographs and notifying the appropriate services; and (3) participating in and communicating with a multidisciplinary team to manage the patients.
PMCID: PMC3032840  PMID: 20941649
19.  The impact of trauma centre designation on open tibial fracture management 
The British Orthopaedic Association/British Association of Plastic, Reconstructive and Aesthetic Surgeons guidelines for the management of open tibial fractures recommend early senior combined orthopaedic and plastic surgical input with appropriate facilities to manage a high caseload. The aim of this study was to assess whether becoming a major trauma centre has affected the management of patients with open tibial fractures.
Data were obtained prospectively on consecutive open tibial fractures during two eight-month periods: before and after becoming a trauma centre.
Overall, 29 open tibial fractures were admitted after designation as a major trauma centre compared with 15 previously. Of the 29 patients, 21 came directly or as transfers from another accident and emergency deparment (previously 8 of 15). The time to transfer patients admitted initially to local orthopaedic departments has fallen from 205.7 hours to 37.4 hours (p=0.084). Tertiary transferred patients had a longer hospital stay (16.3 vs 14.9 days) and had more operations (3.7 vs 2.6, p=0.08) than direct admissions. As a trauma centre, there were improvements in time to definitive skeletal stabilisation (4.7 vs 2.2 days, p=0.06), skin coverage (8.3 vs 3.7 days, p=0.06), average number of operations (4.2 vs 2.3, p=0.002) and average length of hospital admission (26.6 vs 15.3 days, p=0.05).
The volume and management of open tibial fractures, independent of fracture grade, has been directly affected by the introduction of a trauma centre enabling early combined senior orthopaedic and plastic surgical input. Our data strongly support the benefits of trauma centres and the continuing development of trauma networks in the management of open tibial fractures.
PMCID: PMC4165241  PMID: 23827288
Open fracture; Trauma network; Major trauma centre; Gustilo; Tibial fracture
20.  Prevention of Falls and Fall-Related Injuries in Community-Dwelling Seniors 
Executive Summary
In early August 2007, the Medical Advisory Secretariat began work on the Aging in the Community project, an evidence-based review of the literature surrounding healthy aging in the community. The Health System Strategy Division at the Ministry of Health and Long-Term Care subsequently asked the secretariat to provide an evidentiary platform for the ministry’s newly released Aging at Home Strategy.
After a broad literature review and consultation with experts, the secretariat identified 4 key areas that strongly predict an elderly person’s transition from independent community living to a long-term care home. Evidence-based analyses have been prepared for each of these 4 areas: falls and fall-related injuries, urinary incontinence, dementia, and social isolation. For the first area, falls and fall-related injuries, an economic model is described in a separate report.
Please visit the Medical Advisory Secretariat Web site,, to review these titles within the Aging in the Community series.
Aging in the Community: Summary of Evidence-Based Analyses
Prevention of Falls and Fall-Related Injuries in Community-Dwelling Seniors: An Evidence-Based Analysis
Behavioural Interventions for Urinary Incontinence in Community-Dwelling Seniors: An Evidence-Based Analysis
Caregiver- and Patient-Directed Interventions for Dementia: An Evidence-Based Analysis
Social Isolation in Community-Dwelling Seniors: An Evidence-Based Analysis
The Falls/Fractures Economic Model in Ontario Residents Aged 65 Years and Over (FEMOR)
To identify interventions that may be effective in reducing the probability of an elderly person’s falling and/or sustaining a fall-related injury.
Although estimates of fall rates vary widely based on the location, age, and living arrangements of the elderly population, it is estimated that each year approximately 30% of community-dwelling individuals aged 65 and older, and 50% of those aged 85 and older will fall. Of those individuals who fall, 12% to 42% will have a fall-related injury.
Several meta-analyses and cohort studies have identified falls and fall-related injuries as a strong predictor of admission to a long-term care (LTC) home. It has been shown that the risk of LTC home admission is over 5 times higher in seniors who experienced 2 or more falls without injury, and over 10 times higher in seniors who experienced a fall causing serious injury.
Falls result from the interaction of a variety of risk factors that can be both intrinsic and extrinsic. Intrinsic factors are those that pertain to the physical, demographic, and health status of the individual, while extrinsic factors relate to the physical and socio-economic environment. Intrinsic risk factors can be further grouped into psychosocial/demographic risks, medical risks, risks associated with activity level and dependence, and medication risks. Commonly described extrinsic risks are tripping hazards, balance and slip hazards, and vision hazards.
Note: It is recognized that the terms “senior” and “elderly” carry a range of meanings for different audiences; this report generally uses the former, but the terms are treated here as essentially interchangeable.
Evidence-Based Analysis of Effectiveness
Research Question
Since many risk factors for falls are modifiable, what interventions (devices, systems, programs) exist that reduce the risk of falls and/or fall-related injuries for community-dwelling seniors?
Inclusion and Exclusion Criteria
Inclusion Criteria
English language;
published between January 2000 and September 2007;
population of community-dwelling seniors (majority aged 65+); and
randomized controlled trials (RCTs), quasi-experimental trials, systematic reviews, or meta-analyses.
Exclusion Criteria
special populations (e.g., stroke or osteoporosis; however, studies restricted only to women were included);
studies only reporting surrogate outcomes; or
studies whose outcome cannot be extracted for meta-analysis.
Outcomes of Interest
number of fallers, and
number of falls resulting in injury/fracture.
Search Strategy
A search was performed in OVID MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, EMBASE, the Cumulative Index to Nursing & Allied Health Literature (CINAHL), The Cochrane Library, and the International Agency for Health Technology Assessment (INAHTA) for studies published between January 2000 and September 2007. Furthermore, all studies included in a 2003 Cochrane review were considered for inclusion in this analysis. Abstracts were reviewed by a single author, and studies meeting the inclusion criteria outlined above were obtained. Studies were grouped based on intervention type, and data on population characteristics, fall outcomes, and study design were extracted. Reference lists were also checked for relevant studies. The quality of the evidence was assessed as high, moderate, low, or very low according to the GRADE methodology.
Summary of Findings
The following 11 interventions were identified in the literature search: exercise programs, vision assessment and referral, cataract surgery, environmental modifications, vitamin D supplementation, vitamin D plus calcium supplementation, hormone replacement therapy (HRT), medication withdrawal, gait-stabilizing devices, hip protectors, and multifactorial interventions.
Exercise programs were stratified into targeted programs where the exercise routine was tailored to the individuals’ needs, and untargeted programs that were identical among subjects. Furthermore, analyses were stratified by exercise program duration (<6 months and ≥6 months) and fall risk of study participants. Similarly, the analyses on the environmental modification studies were stratified by risk. Low-risk study participants had had no fall in the year prior to study entry, while high-risk participants had had at least one fall in the previous year.
A total of 17 studies investigating multifactorial interventions were identified in the literature search. Of these studies, 10 reported results for a high-risk population with previous falls, while 6 reported results for study participants representative of the general population. One study provided stratified results by fall risk, and therefore results from this study were included in each stratified analysis.
Summary of Meta-Analyses of Studies Investigating the Effectiveness of Interventions on the Risk of Falls in Community-Dwelling Seniors*
CI refers to confidence interval; RR, relative risk.
Hazard ratio is reported, because RR was not available.
Summary of Meta-Analyses of Studies Investigating the Effectiveness of Interventions on the Risk of Fall-Related Injuries in Community-Dwelling Seniors*
CI refers to confidence interval; RR, relative risk.
Odds ratio is reported, because RR was not available.
High-quality evidence indicates that long-term exercise programs in mobile seniors and environmental modifications in the homes of frail elderly persons will effectively reduce falls and possibly fall-related injuries in Ontario’s elderly population.
A combination of vitamin D and calcium supplementation in elderly women will help reduce the risk of falls by more than 40%.
The use of outdoor gait-stabilizing devices for mobile seniors during the winter in Ontario may reduce falls and fall-related injuries; however, evidence is limited and more research is required in this area.
While psychotropic medication withdrawal may be an effective method for reducing falls, evidence is limited and long-term compliance has been demonstrated to be difficult to achieve.
Multifactorial interventions in high-risk populations may be effective; however, the effect is only marginally significant, and the quality of evidence is low.
PMCID: PMC3377567  PMID: 23074507
21.  A computer-assisted systematic quality monitoring method for cervical hip fracture radiography 
Acta Radiologica Open  2016;5(12):2058460116674749.
A thorough quality analysis of radiologic performance is cumbersome. Instead, the prevalence of missed cervical hip fractures might be used as a quality indicator.
To validate a computer-based quality study of cervical hip fracture radiography.
Material and Methods
True and false negative and positive hip trauma radiography during 6 years was assessed manually. Patients with two or more radiologic hip examinations before surgery were selected by computer analysis of the databases. The first of two preoperative examinations might constitute a missed fracture. These cases were reviewed.
Out of 1621 cervical hip fractures, manual perusal found 51 (3.1%) false negative radiographic diagnoses. Among approximately 14,000 radiographic hip examinations, there were 27 (0.2%) false positive diagnoses. Fifty-seven percent of false negative reports were occult fractures, the other diagnostic mistakes. There were no significant differences over the years. Diagnostic sensitivity was 96.9% and specificity 99.8%. Computer-assisted analysis with a time interval of at least 120 days between the first and the second radiographic examination discovered 39 of the 51 false negative reports.
Cervical hip trauma radiography has high sensitivity and specificity. With computer-assisted analysis, 76% of false negative reports were found.
PMCID: PMC5152935  PMID: 27994880
Femoral neck fractures; healthcare quality assurance; radiography; computer-assisted diagnosis; incidence
22.  Treatment With the SIGN Nail in Closed Diaphyseal Femur Fractures Results in Acceptable Radiographic Alignment 
The burden of orthopaedic trauma in the developing world is substantial and disproportionate. SIGN Fracture Care International is a nonprofit organization that has developed and made available to surgeons in resource-limited settings an intramedullary interlocking nail for use in the treatment of femoral and tibial fractures. Instrumentation also is donated with the nail. A prospectively populated database collects information on all procedures performed using this nail. Given the challenging settings and numerous surgeons with varied experience, it is important to document adequate alignment and union using the device.
The primary aim of this research was to assess the adequacy of operative reduction of closed diaphyseal femur fractures using the SIGN interlocking intramedullary nail based on radiographic images available in the SIGN database. The secondary aims were to assess correlations between postoperative alignment and several associated variables, including fracture location in the diaphysis, degree of fracture site comminution, and time to surgery. The tertiary aim was to assess the functionality of the SIGN database for radiographic analyses.
A review of the prospectively populated SIGN database was performed for patients with a diaphyseal femur fracture treated with the SIGN nail, which at the time of the study totaled 32,362 patients. After study size calculations, a random number generator was used to select 500 femur fractures for analysis. Exclusion criteria included open fractures and those without radiographs during the early postoperative period. The following information was recorded: location of the fracture in the diaphysis; fracture classification (AO/Orthopaedic Trauma Association [OTA] classification); degree of comminution (Winquist and Hansen classification); time from injury to surgery; and patient demographics. Measurements of alignment were obtained from the AP and lateral radiographs with malalignment defined as deformity in either the sagittal or coronal plane greater than 5°. Measurements were made manually by the four study authors using on-screen protractor software and interobserver reliability was assessed.
The frequency of malalignment greater than 5° observed on postoperative radiographs was 51 of 501 (10%; 95% CI, 6.5–11.5), and malalignment greater than 10° occurred in eight of 501 (1.6%) of the femurs treated with this nail. Fracture location in the proximal or distal diaphysis was strongly correlated with risk of malalignment, with an odds ratio (OR) of 3.7 (95% CI, 1.5–9.3) for distal versus middle diaphyseal fractures and an OR of 4.7 (95% CI, 1.9–11.5) for proximal versus middle fractures (p < 0.001). Time from injury to surgery greater than 4 weeks also was strongly correlated with risk of malalignment (p < 0.001). Inherent fracture stability, based on fracture site comminution as per the Winquist and Hansen classification (Class 0–1 stable versus 2–4 unstable) showed an OR of 2.3 (95% CI, 1.2–4.3) for malalignment in unstable fractures. Interobserver reliability showed agreement of 88% (95% CI, 83–93) and mean kappa of 0.81 (95% CI, 0.65–0.87). The SIGN database of radiographic images was found to be an excellent source for research purposes with 92% of reviewed radiographs of acceptable quality.
The frequency of malalignment in closed diaphyseal femoral fractures treated with the SIGN nail closely approximated the incidence reported in the literature for North American trauma centers. Increased time from injury to surgery was correlated with increased frequency of malalignment; as humanitarian distribution of the SIGN nail increases, local barriers to timely care should be assessed and improved as possible. Prospective clinical study with followup, despite its inherent challenges in the developing world, would be of great benefit in the future.
Level of Evidence
Level III, therapeutic study.
PMCID: PMC4457748  PMID: 25894807
23.  The epidemiology of reoperations for orthopaedic trauma 
The Royal College of Surgeons of England (RCS) has issued guidance regarding the use of reoperation rates in the revalidation of UK-based orthopaedic surgeons. Currently, little has been published concerning acceptable rates of reoperation following primary surgical management of orthopaedic trauma, particularly with reference to revalidation.
A retrospective review was conducted of patients undergoing clearly defined reoperations following primary surgical management of trauma between 1 January 2010 and 31 December 2011. A full case note review was undertaken to establish the demographics, clinical course and context of reoperation. A review of the imaging was performed to establish whether the procedure performed was in line with accepted trauma practice and whether the technical execution was acceptable.
A total of 3,688 patients underwent primary procedures within the time period studied while 70 (1.90%, 99% CI: 1.39–2.55) required an unplanned reoperation. Thirty-nine (56%) of these patients were male. The mean age of patients was 56 years (range: 18–98 years) and there was a median time to reoperation of 50 days (IQR: 13–154 days). Potentially avoidable reoperations occurred in 41 patients (58.6%, 99% CI: 43.2–72.6). This was largely due to technical errors (40 patients, 57.1%, 99% CI: 41.8–71.3), representing 1.11% (99% CI: 0.73–1.64) of the total trauma workload. Within RCS guidelines, 28-day reoperation rates for hip, wrist and ankle fractures were 1.4% (99% CI: 0.5–3.3), 3.5% (99% CI: 0.8%–12.1) and 1.86% (99% CI: 0.4–6.6) respectively.
We present novel work that has established baseline reoperation rates for index procedures required for revalidation of orthopaedic surgeons.
PMCID: PMC4473898  PMID: 25519265
Reoperation; Orthopaedic trauma; Revalidation; Epidemiology of reoperation
24.  Management of open tibial fractures – a regional experience 
The treatment of soft-tissue injuries associated with tibial diaphyseal fractures presents a clinical challenge that is best managed by a combined plastic and orthopaedic surgery approach. The current study was undertaken to assess early treatment outcomes and burden of service provision across five regional plastic surgery units in the South-West of England.
We conducted a prospective 6-month audit of open tibial diaphyseal fracture management in five plastic surgery units (Bristol, Exeter, Plymouth, Salisbury, Swansea) with a collective catchment of 9.2 million people. Detailed data were collected on patient demographics, injury pattern, surgical management and outcome followed to discharge.
The study group consisted of 55 patients (40 male, 15 female). Twenty-two patients presented directly to the emergency department at the specialist hospital (primary group), 33 patients were initially managed at a local hospital (tertiary group). The mean time from injury to soft tissue cover was significantly less (P < 0.001) in the primary group (3.6 ± 0.8 days) than the tertiary group (10.8 ± 2.2 days), principally due to a delay in referral in the latter group (5.4 ±1.7 days). Cover was achieved with 39 flaps (19 free, 20 local), eight split skin grafts. Nine wounds closed directly or by secondary intention. There were 11 early complications (20%) including one flap failure and four infections. The overall mean length of stay was 17.5 ± 2.8 days.
Multidisciplinary management of severe open tibial diaphyseal may not be feasible at presentation of injury depending on local hospital specialist services available. Our results highlight the need for robust assessment, triage and senior orthopaedic review in the early post-injury phase. However, broader improvements in the management of lower limb trauma will additionally require further development of combined specialist trauma centres.
PMCID: PMC3229382  PMID: 21047449
Open fracture; Soft tissue; Reconstruction; Tibia
25.  An undiagnosed bilateral anterior shoulder dislocation after a seizure: a case report 
Cases Journal  2008;1:342.
Late diagnoses of orthopaedic injuries after epileptic crisis are a matter of concern. The rarity of correlation between seizure and specific trauma incidences such as bilateral anterior shoulder dislocation, may lead to improper estimation of the patient's clinical state, wrong treatment and unpleasant complications.
Case presentation
We report the rare case of an undiagnosed bilateral anterior shoulder dislocation in an epileptic young man of 25 years of age. The way of treatment is described as well as the treating alterations, if needed, because of the 3 weeks delay from injury. The article focuses on the reasons of the non-diagnosis at the first place and proposes a possible explanation for the mechanism of the injury. This is the second documented case of a missed bilateral anterior shoulder dislocation following a seizure and the first one that was treated not earlier than 3 weeks post injury.
Although not a matter of routine, the high importance of radiographic control after seizure, in case of suspicion, is concluded. The etiology causing the injury shall not disorientate the doctors from the possible diagnoses.
PMCID: PMC2596117  PMID: 19025598

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