No abstract

We demonstrate radiological evidence that an external pelvic splint is effective at reducing open book pelvic fractures. Its use in the pre-hospital and emergency department settings should be encouraged in the initial management and resuscitation of patients with pelvic fractures. D etection and treatment of life threatening haemorrhage is an integral part of the trauma primary survey. Pelvic ring disruption, particularly of the anteroposterior (AP) compression (''open book'') type 2 can be associated with exsanguinating haemorrhage. Suggested strategies for control of such haemorrhage centre around stabilisation of the fracture and its primary clot, apposition of fracture surfaces, and reduction of pelvic volume in order to achieve a tamponade effect. Closed reduction of the pelvis and application of a pelvic external fixator can, in theory, achieve all three of these aims. Emergency application of an anterior external fixator is not a trivial procedure, and may compromise definitive pelvic surgery. The time required for location of equipment and fixator application may take up precious minutes in the resuscitation room.A simple alternative to external fixation in the pre-hospital and emergency department environments is the use of noninvasive circumferential compression. 5 We present two cases where a pelvic ring disruption was successfully reduced and stabilised with a temporary, simple, external pelvic splint. CASE REPORTSPatient 1 A 36 year old motorcyclist was admitted with multiple injuries following a head on collision with a car. On arrival he was tachycardic (104 beats/min), and hypotensive (71/34 mmHg). He remained tachycardic despite intensive intravenous fluid replacement with 8 units of blood and 2 units of fresh frozen plasma. A plain anteroposterior pelvis radiograph ( fig 1A) revealed an open book fracture of the pelvis with a pubic symphysis disruption, fractures of the pubic rami, and opening of the right sacroiliac joint. His other injuries were fractures of the right distal radius, left radius and ulna, and soft tissue injuries to the right knee.A pelvic splint (Stuart Pelvic Harness, Medistox Ltd., Blackburn, UK) was applied and once the patient was haemodynamically stable, a computed tomography (CT) scan performed. This demonstrated anatomical reduction of the right sacroiliac joint (fig 1B), and considerable haematoma around the base of the bladder and the pubic symphysis. Internal fixation of the anterior pelvic ring was not felt to be necessary and he was managed with an external fixator. Patient 2A 37 year old male pillion passenger was thrown from a motorcycle and sustained fractures of the right humerus, radius, and ulna, ribs, and pelvis with associated urethral rupture. Plain anteroposterior radiograph of the pelvis, taken as part of the trauma series (fig 2A). His blood pressure remained labile and fluid dependent. There were no other evident sources of blood loss. A pelvic splint was applied in the department, which effectively closed the diastasis. Fluid requirements following ...

There is still much debate on the appropriateness of taking postoperative radiographs following hip fracture surgery. In our unit, it is routine practice to request postoperative radiographs after hip hemiarthroplasty but not after internal fixation. An audit conducted in our unit highlighted the low acute implant-related complications. This prompted us to conduct a national audit on current UK practice regarding the use of check radiographs following hip fracture surgery. Retrospective case note review of all patients undergoing hip fracture surgery at our hospital, from 2002 to 2004, was performed. Patients undergoing revision surgery in the same admission were identified to determine whether check radiograph influenced the decision. Subsequently a postal performa was sent to 450 randomly chosen UK Orthopaedic Consultants. The performa was designed to determine practice relating to postoperative radiographs. It also attempted to determine whether postoperative radiographs (when requested) influenced the subsequent clinical management of the patient. A total of 1265 hip fractures treated surgically were reviewed locally. Average length of stay was 29.5 days. There were five acute implant-related complications. One revision was performed for a long hip screw which was obvious on the intra-operative image intensifier films. Only one decision to revise (because of incongruous reduction of a hip hemiarthroplasty) was based on a problem identified on a routine check radiograph. All patients undergoing revision were clinically symptomatic. We received 300 responses. Ninety-six per cent routinely took postoperative radiographs following hip hemiarthroplasty of which 83% allowed the patient to mobilise before checking the radiograph. Following dynamic hip screw (DHS)/dynamic condylar screw (DCS) fixation, 61% took check radiographs of which 75% allowed the patient to mobilise prior to reviewing the radiograph. Following cannulated screw (CS) fixation, 58% routinely performed check radiographs of which 67% allowed the patient to mobilise before reviewing the radiograph. The study highlights the lack of national consensus on the use of postoperative radiographs. We recommend that following DHS/DCS fixation and CS fixation, the use of postoperative radiographs should only be undertaken when clinically indicated. Postoperative radiographs following hip hemiarthroplasty should only be undertaken if there are operative concerns or postoperative complications.

No abstract

A BSTRACT Background: With the growing and complex nature of medicine, it is imperative for physicians to update their knowledge and skills to reflect current standards of care. In Pakistan, 71% of primary care needs are met by general practitioners (GPs). GPs are not required to complete structured training and no regulatory mandates exist for continuing medical education. We conducted a needs assessment to evaluate the readiness for competency-based updating of knowledge and skills, and the use of technology by practicing GPs in Pakistan. Methods: A cross-sectional survey inviting registered GPs across Pakistan was administered online and in-person. Questions pertained to physician demographics, practice characteristics, confidence in knowledge and skills, and preferred modes of updating knowledge and barriers. Descriptive analyses were performed for GPs and patient-related characteristics and bivariate analyses to evaluate the relationship between parameters of interest. Results: Of the 459 GPs who responded, 35% were practicing for <5 years and 34% reported practicing for >10 years. Only 7% had a post-graduate qualification in family medicine. GPs reported needing practice in neonatal examination (52%), neurological exam (53%), depression screening (53%), growth charts (53%) and peak flow meter use (53%), interpretation of electrocardiograms (ECGs, 58%) and insulin dosing for diabetes (50%). High workload (44%) was the most common barrier to updating clinical knowledge. Sixty-two percent used the Internet on a regular basis. Conclusion: Most GPs have no structured training and encounter gaps in knowledge and skills in clinical practice. Flexible, hybrid, and competency-based continuing medical education programs can be used to update knowledge and skills.