Sensitivity and specificity of patient-entered red flags for lower back pain

Background Context

Red flags are questions typically ascertained by providers to screen for serious underlying spinal pathologies. The utility of patient-reported red flags in guiding clinical decision-making for spine care, however, has not been studied.

Gunshot-induced fractures of the extremities: a review of antibiotic and debridement practices

The use of antibiotic prophylaxis and debridement is controversial when treating low- and high-velocity gunshot-induced fractures, and established treatment guidelines are currently unavailable. The purpose of this review was to evaluate the literature for the prophylactic antibiotic and debridement policies for (1) low-velocity gunshot fractures of the extremities, joints, and pelvis and (2) high-velocity gunshot fractures of the extremities. Low-velocity gunshot fractures of the extremities were subcategorized into operative and non-operative cases, whereas low-velocity gunshot fractures of the joints and pelvis were evaluated based on the presence or absence of concomitant bowel injury. In the absence of surgical necessity for fracture care such as concomitant absence of gross wound contamination, vascular injury, large soft-tissue defect, or associated compartment syndrome, the literature suggests that superficial debridement for low-velocity ballistic fractures with administration of antibiotics is a satisfactory alternative to extensive operative irrigation and debridement. In operative cases or those involving bowel injuries secondary to pelvic fractures, the literature provides support for and against extensive debridement but does suggest the use of intravenous antibiotics. For high-velocity ballistic injuries, the literature points towards the practice of extensive immediate debridement with prophylactic intravenous antibiotics. Our systematic review demonstrates weak evidence for superficial debridement of low-velocity ballistic fractures, extensive debridement for high-velocity ballistic injuries, and antibiotic use for both types of injury. Intra-articular fractures seem to warrant debridement, while pelvic fractures with bowel injury have conflicting evidence for debridement but stronger evidence for antibiotic use. Given a relatively low number of studies on this subject, we recommend that further high-quality research on the debridement and antibiotic use for gunshot-induced fractures of the extremities should be conducted before definitive recommendations and guidelines are developed.

Electronic supplementary material

The online version of this article (doi:10.1007/s12178-015-9284-9) contains supplementary material, which is available to authorized users.     

Relationship between the Charlson Comorbidity Index and cost of treating hip fractures: implications for bundled payment

BackgroundThe aim of this study is to investigate how the Charlson Comorbidity Index (CCI) scores contribute to increased length of stay (LOS) and healthcare costs in hip fracture patients.ResultsMultivariate linear regression analysis modeled the length of stay as a function of CCI score. Each unit increase in the CCI score corresponded to an increase in length of hospital stay and hospital costs incurred [effect size = 0.21; (0.0434–0.381); p = 0.014]. Patients with a CCI score of 2 (compared to a baseline CCI score of 0), on average, stayed 1.92 extra days in the hospital, and incurred $8,697.60 extra costs.ConclusionsThe CCI score is associated with length of stay and hospital costs incurred following treatment for hip fracture. The CCI score may be a useful tool for risk assessment in bundled payment plans.

Level of evidence

Level III.     

Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Venous blood gas in adult patients with diabetic ketoacidosis

Report by Ziauddin Hassan, Devasena M Subramonyam, Registrars
Checked by Shobhan Thakore, Specialist Registrar     

Olecranon fractures: factors influencing re-operation

Purpose

We evaluated factors influencing re-operation in tension band and plating of isolated olecranon fractures.

Methods

Four hundred eighty-nine patients with isolated olecranon fractures who underwent tension band (TB) or open reduction internal fixation (ORIF) from 2003 to 2013 were identified at an urban level 1 trauma centre. Medical records were reviewed for patient information and complications, including infection, nonunion, malunion, loss of function or hardware complication requiring an unplanned surgical intervention. Electronic radiographs of these patients were reviewed to identify Orthopaedic Trauma Association (OTA) fracture classification and patients who underwent TB or ORIF.

Results

One hundred seventy-seven patients met inclusion criteria of isolated olecranon fractures. TB was used for fixation in 43 patients and ORIF in 134. No statistical significance was found when comparing complication rates in open versus closed olecranon fractures. In a multivariate analysis, the key factor in outcome was method of fixation. Overall, there were higher rates of infection and hardware removal in the TB compared with the ORIF group.

Conclusions

Our results demonstrate that the dominant factor driving re-operation in isolated olecranon fractures is type of fixation. When controlling for all variables, there is an increased chance of re-operation in patients with TB fixation.     

Difference in injury pattern between drivers and front seat passengers involved in road traffic accidents in Scotland

Methods: Using the Scottish Trauma Audit Group (STAG) database from 1994 to 2000, a search for injuries to eight anatomical body regions was performed. Injuries were identified and selected by their abbreviated injury score code. A comparison of injury frequency between drivers and front seat passengers was then made.

Results: There were 4189 drivers and 954 front seat passengers included in the study. Mortality was higher in the "front seat passengers" group (6.6% compared with 5.3% p = 0.13). Seven of the eight body regions selected showed higher rates of injury in front seat passengers. There were significantly more injuries to cervical spine (6.0% compared with 3.3% p0.001), chest (41.4% compared with 29.0% p0.001), and lumber spine (7.4% compared with 5.2% p0.001) in front seat passengers.

Conclusions: Front seat passengers are at increased risk of injury relative to drivers in actual road traffic accidents as recorded in the STAG database. This contradicts crash test data, which suggest drivers are less well protected than front seat passengers in laboratory conditions.