Pain after trauma has received relatively little research attention compared with surgical techniques and functional outcomes, but is important to patients. We aimed to describe nerve dysfunction and pain characteristics using tibial fractures as a model. We hypothesized that early nerve dysfunction was associated with neuropathic and chronic pain. Adult patients with isolated open or closed tibial diaphyseal fractures were prospectively observed for 1-year in 5 Major Trauma Centres. Nerve dysfunction was assessed using Semmes-Weinstein monofilaments, acute pain with the visual numerical rating scale (VNRS), neuropathic pain with the doleur neuropathique-4 score and quality of life (QOL) using the EQ-5D score.Introduction
Materials and Methods
The management of open lower limb fractures in the United Kingdom
has evolved over the last ten years with the introduction of major
trauma networks (MTNs), the publication of standards of care and
the wide acceptance of a combined orthopaedic and plastic surgical approach
to management. The aims of this study were to report recent changes
in outcome of open tibial fractures following the implementation
of these changes. Data on all patients with an open tibial fracture presenting
to a major trauma centre between 2011 and 2012 were collected prospectively.
The treatment and outcomes of the 65 Gustilo Anderson Grade III
B tibial fractures were compared with historical data from the same
unit. Aims
Patients and Methods
In this study we quantified and characterised
the return of functional mobility following open tibial fracture
using the Hamlyn Mobility Score. A total of 20 patients who had
undergone reconstruction following this fracture were reviewed at
three-month intervals for one year. An ear-worn movement sensor
was used to assess their mobility and gait. The Hamlyn Mobility
Score and its constituent kinematic features were calculated longitudinally,
allowing analysis of mobility during recovery and between patients
with varying grades of fracture. The mean score improved throughout
the study period. Patients with more severe fractures recovered
at a slower rate; those with a grade I Gustilo-Anderson fracture
completing most of their recovery within three months, those with
a grade II fracture within six months and those with a grade III
fracture within nine months. Analysis of gait showed that the quality of walking continued
to improve up to 12 months post-operatively, whereas the capacity
to walk, as measured by the six-minute walking test, plateaued after
six months. Late complications occurred in two patients, in whom the trajectory
of recovery deviated by >
0.5 standard deviations below that of
the remaining patients. This is the first objective, longitudinal
assessment of functional recovery in patients with an open tibial
fracture, providing some clarification of the differences in prognosis
and recovery associated with different grades of fracture. Cite this article:
St Mary's Hospital, the major trauma centre for West London, treated 168 patients with lower limb open fractures in 2011 & 2012. This audit compared antibiotic administration in the emergency department against the current BOAST IV guidelines. The choice, timing, dose, and documentation of antibiotic administration was collected from the casualty cards and the transfer documentation for any patient initially seen at another hospital. The severity of the injury (as the Gusitollo-Anderson classification) after the initial debridement and any infectious complications that presented before discharge were also recorded. The results showed a higher compliance with the BOAST IV guidelines for those patients directly admitted rather than transferred to the major trauma centre. In direct admissions the recommended antibiotics were either not given or not adequately documented in 7% of cases. In those patients transferred from another emergency department the documentation was inadequate in 27% of cases. The likely causes of these results are discussed alongside the unit's bone infection rates.
