Students continue to feel unprepared for the responsibility of clinical decision making. A teaching intervention, including simulated individual clinical scenarios, later in undergraduate training, appeared to be useful in improving medical students' decision making, specifically in relation to making a diagnosis, prioritising, asking for help and multi-tasking, but further work is required.

Simulated teaching is a relatively easy yet effective way to teach prioritisation and other skills. We hope that our method is self-explanatory and could be adapted for other teaching groups or material.

Introduction:The unique attributes of distributed ledger blockchain systems including robust security, immutability, transparency, and decentralisation, make them highly suitable solutions for many healthcare-related problems. This review examines the potential applications for blockchain technology in the field of orthopaedics, by taking a systematic approach to the evolving blockchain literature and mapping potential use cases against the current needs of orthopaedic practice. Method: A literature search was performed using Pubmed, EMBASE, OVID and the Cochrane library with the primary aim of identifying detailed accounts of blockchain solutions and use cases in healthcare. These articles were then reviewed and mapped against current orthopaedic practice to illustrate applications specific to that specialty. Results: One hundred and forty-one papers were identified which described case studies, simulations, or detailed proposals of blockchain solutions in healthcare. Most studies described blockchain solutions at the simulated or prototype testing phase, with only 10 case studies describing blockchains in "realworld" use. The most frequently cited use cases for blockchain technology involved the storage, security and sharing of electronic medical records. Other blockchain solutions focused on the "Internet of Things", research, COVID 19, supply chains and radiology. There were no solutions focusing specifically on orthopaedics. Many of the described blockchain solutions had considerable scope for application in orthopaedic practice however, providing the potential for greater inter-institutional collaboration, cross border data exchange, enhanced patient participation, and more robust and transparent research practices. Conclusion: Blockchain solutions for healthcare are increasing in number and scope and have multiple applications relevant to orthopaedic practice. The orthopaedic community needs to be aware of this innovative and growing field of computer science so that surgeons can leverage the power of blockchain safely for the future of orthopaedics.

Metastatic bone disease (MBD) is a frequently encountered condition in trauma and orthopaedic practice, and delayed or inappropriate management may lead to worse oncological outcomes, dysfunction and reoperation. Updated guidance from the British Orthopaedic Oncology Society (BOOS) and British Orthopaedic Association (BOA), in 2015, aimed to raise awareness of such risks and to set clear standards for the provision of care in MBD patients. However, it is unclear whether these recommendations have been routinely adopted into clinical practice. BOOS and BOA aim to revise and update this guidance, and British Orthopaedic Association Standard for Trauma (BOAST) guidelines relating to MBD management are due to be published. The aim of this collaborative audit is to evaluate and benchmark current practice in the management of MBD prior to the publication of these BOAST guidelines, providing a baseline comparison for further future re-audit.

Patients with acute tendo-achilles (TA) rupture require prompt diagnosis, investigation and treatment in order to ensure optimum outcomes. This can be prevented by delay in review of patients within secondary care. We present our experience of treating such injuries by establishing a "virtual" fracture clinic (VFC) and a one stop dedicated TA specialist clinic. Patients are referred to the service via the emergency department (ED) and are triaged remotely by the VFC, at which all orthopaedic cases including suspected TA injuries are reviewed by a consultant orthopaedic surgeon using all available medical records and imaging. Suitable patients are then diverted directly to the specialist TA clinic for definitive treatment. We wished to establish the speed and efficiency of this care pathway. Methods: Using our institutions prospectively maintained database, we identified patients treated in the specialist TA clinic between September 2016 and August 2017. We recorded demographic details, injury mechanism, time from injury to diagnosis, ultrasound scan findings, and the speed of progress of the patient along the agreed rehabilitation pathway. Results: Sixty two patients were referred to the VFC with suspected TA injury. Mean age was 49 years, M:F (44:18 female). Mean time to triage in the VFC was 3.5 days (with 42% of patients triaged in the VFC on the same day as initial ED presentation). Mean time from ED consultation to assessment in our TA clinic was 11.7 days. Patients were assessed by a specialist foot and ankle surgeon, supported by a same day musculoskeletal ultrasound service. 45 patients (74%) were diagnosed with TA rupture, of which 69% were acute complete ruptures. Eight patients fulfilled criteria for surgical repair. Mean time from ED consultation to surgery was 13.25 days. Three further patients treated non-operatively developed secondary ruptures requiring delayed operative intervention. Conclusion: We recommend the use of a virtual triage service and a one stop TA clinic led by a dedicated specialist team to improve the accuracy of diagnosis and efficacy of treatment of acute TA rupture. This service provides a robust system for avoiding mis-diagnoses and delays in treatment, as well as ensuring effective implementation of our local care pathway under specialist supervision in a one stop clinic. This also establishes an effective system for monitoring as well as maintaining a research database for further prospective studies.