Note: No previous similar study to this has been carried out in the Republic of Ireland, to our knowledge. Ankle fractures are the most common lower limb fracture in all age groups in Ireland. Approximately 43% of all ankle fractures will require operative fixation.1 82% of all operative ankle procedures in Ireland are carried out on patients between 18–65 years old. We felt it was imperative to study the incidence within various age groups, the associated length of hospital stay and to offer suggestions in reducing this length-of-stay. The National Hospital Inpatient Enquiry system (data collection accuracy 95.9%–98.2%), ICD-coding and data from the Central Statistics Office were analysed.2 14,903 ankle fractures underwent ORIF between 2002–09 (average 1,928/year). While there was a statistical increase in ORIF's in the over 65 group, there was no overall increase in the incidence of surgical procedures. The average length-of-stay in 2002 was 4.8 days, but had significantly dropped to 4.0 days by 2009. This was most marked in the over 65's where it decreased from 10.5 to 7.7 days. The annual incidence of ankle fractures requiring operative intervention in Ireland was 44.43 per 100,000 persons. This study highlights many issues, namely:
While there is a significant decrease in length-of-stay to 4 days, we feel this figure could be significantly reduced further. While the incidence of ankle fractures in the over-65 group remained stable, surprisingly there was a statistically significant increase in the number of operative procedures within this age group.
An interesting case with excellent accompanying images, highlighting the significance of tourniquets in controlling exsanguination, whilst also raising the issue of amputation versus reconstruction in severely injured limbs. A 39 year old male motorcyclist was BIBA to the Midland Regional Hospital in Tullamore, following a head-on collision with a bus at high velocity. On arrival, he was assessed via ATLS guidelines; A- intubated, B- respiratory rate 32, C - heart rate 140bpm, blood-pressure 55/15 and D- GCS 7/15. Injuries included partial traumatic amputation of the right lower limb with clearly visible posterior femoral condyles, a heavily comminuted distal tibial fracture and almost complete avulsion of the skin and fat at the popliteal fossa. Obvious massive blood loss at the scene had been tempered by a passer-by who applied a beach towel as a makeshift tourniquet. CT Brain demonstrated extra-dural and subarachnoid haemorrhages with gross midline shift. Unfortunately, the neurosurgical team in Beaumont concluded that surgical intervention would be inappropriate. However, his kidneys had not sustained ATN and were made available for donation. Two vital surgical issues were featured in this case. Firstly, it highlighted the importance of tourniquets in controlling exsanguination in a trauma situation1. Secondly, it raised the critical issue of amputation versus reconstruction in severely injured limbs2,3. Without prompt placement of a make-shift tourniquet by a passer-by, this patient would have almost certainly died at the scene of the accident. Two kidneys were successfully donated as a result. The importance of appropriate tourniquet use cannot be overstated. This case highlights its potential life or limb-saving capabilities in emergency trauma situations. It also raises the critical issue of amputation versus reconstruction in acute emergency situations.
