Diagnostic accuracy of lower extremity X-ray interpretation by 'specialized' emergency nurses.

OBJECTIVES: In the quest for a cost-effective and quality-preserving solution to manage crowding in the emergency department, the possibility of deploying regular emergency nurses for the treatment of acute ankle injuries was investigated. The aim of this study is to compare the diagnostic accuracy of emergency nurses with that of senior house officers in interpreting ankle and foot radiographs. METHODS: A prospective study comparing the assessment of 60 radiographs (30 feet and 30 ankles) by 16 emergency nurses before and after an educational session was performed. Each subset of 30 radiographs contained 12 fractures, hand-picked by a radiologist to represent everyday traumatology in the emergency department. The control group consisted of eight senior house officers representing everyday expertise. The outcome of the diagnostic assessment, represented as the pooled sensitivity and specificity for both groups, was compared using Z-statistics. RESULTS: Before the training session, the specialized emergency nurse group showed a sensitivity of 0.87 (confidence interval 0.83-0.91) compared with 0.93 (confidence interval 0.88-0.96) for the control group (P = 0.05). The specificity of specialized emergency nurses was 0.87 (confidence interval 0.81-0.92) compared with 0.93 (confidence interval 0.89-0.95) for the senior house officers (P < 0.05). After the training session, specialized emergency nurse diagnostic parameters did not differ significantly from the control group, displaying a sensitivity of 0.89 (confidence interval 0.86-0.92) and specificity of 0.92 (confidence interval 0.87-0.95). CONCLUSION: Before the training session, the specialized emergency nurse group showed a significantly lower accuracy than the SHO group. After training, however, the diagnostic accuracy did not differ significantly between groups. Therefore, we conclude that emergency nurses are able to accurately interpret foot and ankle radiographs after a short educational session.     

Retrosternal dislocation of the clavicle.

Retrosternal dislocation of the clavicle is an uncommon injury which may affect the mediastinal structures in a life-threatening way. Therefore, computed tomography is mandatory. Manipulation in the acute situation is the treatment of choice. In case of failure or old dislocation, open reduction with stabilization of the joint is required. The literature on this subject has been reviewed and an additional two cases are reported.     

First histological observations on the incorporation of a novel calcium phosphate bone substitute material in human cancellous bone

Calcium phosphates are frequently used as bone substitute materials because of their similarity to the mineral phase of bone, absence of antigenicity, and excellent osteoconductivity. However, in most currently available mineral substitutes, resorption occurs slowly if at all. In contrast, calcium phosphate cements have shown rapid resorption and remodeling in animal studies. In two prospective studies, a novel amorphous calcium phosphate cement (Biobon) was implanted in human patients for the first time. After 2-12 months, ten biopsies were obtained from nine individuals during secondary surgical interventions, for example, for implant removal. In all specimens, partial replacement of the material by new bone was observed, while residues of the cement were still visible. Undecalcified sections revealed extensive bone formation in immediate contact to the cement without fibrous interface. Polynucleated cells and superficial lacunae were indicative of resorptive activity, but inflammatory tissue response was absent. The new bone displayed regular trabecular and osteonal patterns. The histologic findings are in accordance with the excellent biocompatibility observed in the clinical follow-up. Though still incomplete, the resorbability of this cement appears superior to sintered calcium phosphates in these biopsy specimens. Presumably this is due to its amorphous crystalline structure. Biobon merits further studies as a promising substance for bone defect reconstruction in non-stress-bearing areas.     

Ranking institutional settings based on publications in community psychology journals

Two primary outlets for community psychology research, the American Journal of Community Psychology and the Journal of Community Psychology, were assessed to rank institutions based on publication frequency and scientific influence of publications over a 32‐year period. Three specific periods were assessed (1973–1983, 1984–1994, 1995–2004). Findings indicate that there were a large group of institutions that published articles during these periods. Those academic institutions that had the most published articles as well as the largest influence, based on citations by other authors, were identified. Using archival data from the community psychology literature represents one approach for identifying those settings that made substantial contributions to the development and growth of the field. © 2007 Wiley Periodicals, Inc. J Comm Psychol 35: 967–979, 2007.     

Destination of debris during intramedullary reaming. An experimental study on sheep femurs

This study was designed to further explain the better fracture healing in fractures treated with a reamed nail. It investigates the location and quantity of the reaming debris in an ex vivo animal model to test the autograft theory. In 10 cadaveric sheep femurs, a 5-mm semicircular gap was created at the midshaft. The medullary cavity was opened and the reaming debris that dropped from the gap during reaming and the debris from the proximal opening were collected and weighed separately. The mean harvest of reaming debris at the gap was 0.99 g +/- 0.12 g (24%) and from the proximal opening at the medullary cavity 3.08 g +/- 0.31 g (76%) (total 4.07 +/- 0.34 g). This study proves that a significant amount of reaming debris collects at an artificial fracture gap during reaming of the medullary cavity. This finding supports the theory of bone autografting.     

Outcome after modified Putti-Platt procedure for recurrent traumatic anterior shoulder dislocations

Most recent studies on procedures for stabilizing the glenohumeral joint focus on arthroscopic techniques. A relatively simple open procedure is the modified Putti-Platt procedure. The aim of these retrospective case series was to evaluate the functional outcome, patient satisfaction, and quality of life of patients who underwent this procedure. After a median follow-up time of 4.7 (P₂₅–P₇₅ 1.7–6.8) years, fifty-one patients could be enrolled with a mean age of 25 (21–39) years. Five patients (10 %) reported re-dislocations. The median Constant score for the affected side was 84 (P₂₅–P₇₅ 75–91). Median loss of motion in abduction, elevation, external rotation, and external rotation in 90° of abduction did not exceed 10° when compared to the healthy shoulder. A median Rowe score of 92 (P₂₅–P₇₅ 75–95) was measured. The WOSI score and SF-36 showed excellent quality of life. The VAS proved high patient satisfaction with the outcome; 7.9 (6.8–9.5). We concluded that the modified Putti-Platt procedure leads to excellent outcome scores and only marginal restriction in range of motion combined with a high patient satisfaction. Our data prove that excellent results can be obtained with a relatively simple open procedure.     

Good Functional Recovery of Complex Elbow Dislocations Treated With Hinged External Fixation: A Multicenter Prospective Study

BackgroundAfter a complex dislocation, some elbows remain unstable after closed reduction or fracture treatment. Function after treatment with a hinged external fixator theoretically allows collateral ligaments to heal without surgical reconstruction. However, there is a lack of prospective studies that assess functional outcome, pain, and ROM.Questions/purposesWe asked: (1) In complex elbow fracture-dislocations, does treatment with a hinged external fixator result in reduction of disability and pain, and in improvement in ROM, function, and quality of life? (2) Does delayed treatment (7 days or later) have a negative effect on ROM after 1 year? (3) What are the complications seen after external fixator treatment?MethodsDuring a 2-year period, 11 centers recruited 27 patients 18 years or older who were included and evaluated at 2 and 6 weeks and at 3, 6, and 12 months after surgery as part of this prospective case series. During the study period, the participating centers agreed on general indications for use of the hinged external fixator, which included persistent instability after closed reduction alone or closed reduction combined with surgical treatment of associated fracture(s), when indicated. Functional outcome was evaluated using the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH; primary outcome) score, the Mayo Elbow Performance Index (MEPI), the Oxford Elbow Score, and the level of pain (VAS). ROM, adverse events, secondary interventions, and radiographs also were evaluated. A total of 26 of the 27 patients (96%) were available for followup at 1 year.ResultsAll functional and pain scores improved. The median QuickDASH score decreased from 30 (25^th–75^th percentiles [P₂₅–P₇₅], 23–40) at 6 weeks to 7 (P₂₅–P₇₅, 2–12) at 1 year with a median difference of −25 (p < 0.001). The median MEPI score increased from 80 (P₂₅–P₇₅, 64–85) at 6 weeks to 100 (P₂₅–P₇₅, 85–100) at 1 year with a median difference of 15 (p < 0.001). The median Oxford Elbow Score increased from 60 (P₂₅–P₇₅, 44–68) at 6 weeks to 90 (P₂₅–P₇₅, 73–96) at 1 year with a median difference of 29 (p < 0.001). The median VAS decreased from 2.8 (P₂₅–P₇₅, 1.0–5.0) at 2 weeks to 0.5 (P₂₅–P₇₅, 0.0–1.9) at 1 year with a median difference of −2.1 (p = 0.001). ROM also improved. The median flexion-extension arc improved from 50° (P₂₅–P₇₅, 33°–80°) at 2 weeks to 118° (P₂₅–P₇₅, 105°–138°) at 1 year with a median difference of 63° (p < 0.001). Similarly, the median pronation-supination arc improved from 90° (P₂₅–P₇₅, 63°–124°) to 160° (P₂₅–P₇₅, 138°–170°) with a median difference of 75° (p < 0.001). At 1 year, the median residual deficit compared with the uninjured side was 30° (P₂₅–P₇₅, 5°–35°) for the flexion-extension arc, and 3° (P₂₅–P₇₅, 0°–25°) for the pronation-supination arc. Ten patients (37%) experienced a fixator-related complication, and seven patients required secondary surgery (26%). One patient reported recurrent instability.ConclusionsA hinged external elbow fixator provides enough stability to start early mobilization after an acute complex elbow dislocation and residual instability. This was reflected in good functional outcome scores and only slight disability despite a relatively high complication rate.

Level of Evidence

Level IV, therapeutic study.     

Adherence to a femoral neck fracture treatment guideline

Purpose

In 2007 the Dutch Surgical Society published a clinical practice guideline for the treatment of hip fracture patients, based on the best available international evidence at that time. We investigated to what extent treatment of femoral neck fracture patients in the Netherlands corresponded with these guidelines, and determined differences in patient characteristics between the treatment groups.

Methods

All femoral neck fracture patients treated in 14 hospitals between February 2008 and August 2009 were included. Patient characteristics, X-rays, and treatment data were collected retrospectively.

Results

From a total of 1,250 patients 59 % had been treated with arthroplasty, 39 % with internal fixation, and 2 % with a non-operative treatment. While 74 % of the treatment choices complied with the guideline, 12 % did not. In 14 % adherence could not be determined from the available data. Arthroplasty was preferred over internal fixation in elderly patients with severe comorbidity, pre-fracture osteoporosis and a displaced fracture, who were ambulatory with aids pre-fracture (odds ratio, OR 2.2–58.1). Sliding hip screws were preferred over cancellous screws in displaced fractures (OR 1.9).

Conclusions

Overall guideline adherence was good. Most deviations concerned treatment of elderly patients with a displaced fracture and implant use in internal fixation. Additional data on these issues, preferably at a higher scientific level of evidence, is needed in order to improve the guideline and to reinforce a more uniform treatment of these patients.