Introduction: Dr Foster data presents mortality rate for fracture neck of femur in acute trusts. We assessed the accuracy of this data in an acute trust in England for a nine-month period.

Methods: Fifty-seven patients (17.2%) died due to fracture NOF during our review period according to Dr Foster. Medical notes were retrospectively analysed in detail. There were 20 males with a mean age of 84.5yrs (64–100) and 37 females with a mean age of 85.7yrs (57–100). Data analysis included time and day of admission, admission ward, senior orthopaedic review, anaesthetic review, ASA grade, time to surgery, grade of anaesthetist and operating surgeon, type of anaesthesia, time of anaesthesia and surgery, type of surgery, post-op recovery and cause of death.

Results: Seven patients died before their planned surgery due to extensive medical co-morbidity and 50 patients (15.1%) underwent surgery as planned. Thirty-one patients (9.4%) died under the care of the orthopaedic team and were considered by the assessors to be true death due to fracture neck of femur. Eleven patients (3.3%) died in the community after discharge home some several months later. Eight patients (2.4%) died under the care of the rehabilitation team, some months later, the majority from medical causes. The mean time to surgery was 2.7 days (0–13), which was mainly affected by weekend admissions. There were no records of the cause of death in 20 patients including all those that were discharged to the community. Admission time, ward and type and duration of anaesthesia had no effect on mortality rate.

Conclusion: In our review Dr Foster overestimated true death rate due to fracture neck of femur. This trend is worrying as such indicators are linked to financial and performance targets for trusts. Accurate data presentation is therefore imperative and Dr Foster does not appear to deliver this.

Aims: To show that the treatment of buckle fractures in children in a soft bandage, rather than a plaster cast, is an effective and safe method of treatment. Methods: In order to determine the difference between the two groups it was decided to compare the range of movement at three weeks. Power calculations were performed. This gave a required sample size of 23 for each group. The project was submitted for ethical approval in July 1999. Patients enter the trial after parents agree and sign the consent form. Allocation to either plaster or bandage is random and parents draw previously sealed envelopes themselves. Patients are seen each week and measurements taken of their range of movement. Results: Thirty seven patients have completed the study. 17 have been allocated to bandage the rest to cast. Those in bandage show an excellent range of movement at the þrst week with no reported problems on their questionnaires. One patient has transferred from bandage to plaster at the request of the parents. Conclusion: Results suggest a positive result for treatment in bandage with no reported adverse effects and, a highly desirable result for the patient. We would hope to suggest a change in treatment policy for such fractures.

Aims: To show that ankle fusion using an intra-medullary nail is effective with low morbidity and high patient satisfaction and improvement in postoperative AOFAS scores in selected patients. Methods: The þrst twenty ankle fusions performed with the Biomet intra-medullary nailing system by one surgeon were reviewed over a two year period. The Biomet system offers superior advantages, allowing longitudinal compression and posterior to anterior distal locking in the calcaneus.

Data sets were recorded for each patient. Information with regard to each patients age, sex, occupation, presenting complaint, mechanism of injury if applicable, index procedure if applicable, diabetic status, associated comorbidities and smoking habitus were recorded. The pre-operative and post-operative AOFAS score was also recorded for each patient. Results: All patients except one showed a marked improvement in their AOFAS score when treated with intra-medullary nail for ankle fusion. The average improvement in score was 150%. Morbidity from the procedure was low. There was one case of mortality not attributed to the nail. 19 out of 20 patients went on to solid fusion. Conclusion: The use of an intra-medullary nail for fusion of the ankle is a reliable technique in selected cases. AOFAS scores consistently improve, morbidity is low and fusion is usually successful. We would advocate this technique for fusion.

Objectives: To show that the treatment of buckle fracture in children in a soft bandage, rather than a plaster cast, is an effective and safe method of treatment, with an earlier return to normal function.

Methods: In order to determine the difference between the two groups it was decided to compare the range of movement at three weeks. Power calculations were performed using the minimum difference for a two-sample t-test method and assuming a non-central distribution. The calculation was performed on Minitab release version 12.1 Assuming a required difference of 5 degrees and a standard deviation of 5 degrees also with a required power of 0.9(90%) this gave a required sample size of 23 for each group i.e a total of 46 patients. Guidelines for the parents, consent forms, doctor and nurse protocols, a guidance poster for the A& E, treatment profiles for each patient and a questionnaire for parents were written. The project was submitted for ethical approval in July 1999 and granted at the end of that month. Patients enter the trial after parents agree and sign the consent form. Allocation to either plaster or bandage is random and parents draw previously sealed envelopes themselves. Those allocated to bandage are seen each week and measurements taken of their range of movement.

Results: Thirty seven patients have completed the study. 17 have been allocated to bandage the rest to cast. Those in bandage show an excellent range of movement at the first week with no reported problems on their questionnaires. One patient has transferred from bandage to plaster at the request of the parents. Problems encountered have been compliance of those in bandage to return for follow up after two weeks and, ensuring all patients enter the trial and attend the right clinic.

Conclusion: Results suggest a positive result for treatment in bandage with no reported adverse effects and, a highly desirable result for the patient. We would hope to suggest a change in treatment policy for such fractures.

To assess whether the ATLS guidelines were being followed within the Accident and Emergency department of a major DGH and suggest a protocol for assessment in future cases.

The case records and original X-rays of one hundred sequential patients presenting to the Royal Gwent Hospital who received cervical spine x-rays were reviewed retrospectively. Data sets were recorded for each patient including mechanism of injury, recorded opinion of the cervical spine film, diagnosis within the accident and emergency and discharge or admission. The cervical spine films were then reviewed by the authors and assessed for adequacy of visualisation of the C7-T1 junction as required by the ATLS guidelines.

Of the 100 patients 34 of the films assessed were found to have inadequate visualisation of the C7-T1 junction as required by the ATLS guidelines. Swimmers’ views had been obtained in 12 of these patients. The age range was from 9 to 83 years of age.

21 of the 34 had been involved in Road traffic Accidents, 7 in falls, 4 in sport, 1 in an assault and 1 was a case of spontaneous onset neck pain. Diagnoses included neck sprain in 17 cases, bruising in 3 cases, and whiplash in 3 cases. No diagnosis was offered in 11 cases. No specialist opinion was obtained for any of the 34 cases who received inadequate visualisation of their cervical spine. 56 of the 100 patients had satisfactory visualisation of the C7-T1 junction. Films were unavailable for 9 patients.

Visualisation of C7-T1 acute cervical trauma can be difficult. The use of swimmers’ views is a helpful adjunct but these can be difficult to interpret. In the absence of adequate visualisation of the C7-T1 junction injury cannot be excluded. A specialist or senior opinion should be sought with recourse to CT or MRI imaging if cervical spine pathology is suspected, but not excluded with initial radiographs.

To determine whether the Dynamic Condylar Screw, DCS, is suitable in treating pathological subtrochanteric fractures of the femur and the incidence of failure with this device.

Nineteen sequential and unselected patients with twenty femurs with pathological subtrochanteric fractures, or impending fractures, were identified, which had been treated with DCS. Mean age was seventy. Follow up was until functional union (minimum follow up 18 months) or until death. Primary tumour was identified in seventeen of the nineteen cases.

Grade of surgeon was recorded as was the use of adjunctive measures at the time of surgery (PMMA). Subsequent failure, cause and need for revision was noted.

Operative morbidity was low and initial pain relief good in all cases. Two fractures went on to unite. Eight original implants survived until the patient died (mean survival time 24 days). Ten implants failed (50%). Failure resulted from fracture through the DCS plate in eight cases and cut out of the screw in the other two. Of these, five patients (6 femurs) went on to further operative procedures. The others were either deemed unfit (3 cases) or refused further surgery (1 case).

In the light of newer intramedullary techniques we feel the DCS should be used with caution in this type of fracture. DCS in this fracture is associated with a high degree of failure.