Introduction: Open fracture management in the United Kingdom and several other countries is guided by the British Orthopaedic Association's Standards for Trauma Number 4 (BOAST-4). This is updated periodically and is based on the best available evidence at the time. The aim of this study is to evaluate the evidence base forming this guidance and to highlight new developments since the last version in 2017. Methods: Searches have been performed using the PubMed, Embase and Medline databases for time periods a) before December 31, 2017 and from 01/01/2018e01/02/2021. Results have been summarized and discussed. Discussion: Several contentious issues remain within the 2017 guideline. Antibiotic guidance, the use of antibiotic impregnated PMMA beads and intramedullary devices, irrigation in the emergency department, time to theatre and the use of negative pressure dressings and guidance regarding the management of paediatric injuries have all demonstrated no clear consensus. Conclusion:The advent of the BOAST-4 guideline has been of huge benefit, however the refinement and improvement of this work remains ongoing. There remains a need for further study into these contentious issues previously listed.
Aim Spinal Cord Injuries (SCI) are incredibly debilitating injuries associated with significant morbidity and financial burden, with an incidence of 12-16 per million population in the UK. There is currently no cure for SCI, with majority of interventions focusing on primary prevention of SCI or of further damage once SCI is sustained. We present an overview of the role of closed reduction, timing of surgery and role of steroids, and provide an algorithm for management of SCI. Method A search was carried out on PubMed, looking at notable reviews, consensus statements and trends in management of spinal cord injuries. This was cross-referenced with the NICE and BOAST guidelines for SCI. Results The efficacy of closed reduction in cervical fractures and necessity of pre-reduction MRI is still equivocal and remains a source of major debate amongst spinal surgeons. The timing of surgery remains controversial as studies have not consistently shown improved outcomes with early, aggressive surgery but there have been trends noted in the newer studies with some benefit of early surgery. The use of steroids in acute SCI has fallen out of favour with most guidelines not recommending them due to their equivocal benefit and unequivocal side-effect profile. Conclusions Prevention and pre-hospital management are crucial in the management of SCI, along with early spinal alignment restoration, decompression and stabilisation augmented by good long-term rehabilitation measures. There is a need for new randomised controlled trials assessing the role of closed reduction, need for pre-reduction MRI and timing of surgery in SCI.
Aim Complex limb injuries usually comprise of a combination of osseous, soft tissue, vascular and neural damage, necessitating prompt and accurate initial examination and decision-making to maximise optimal patient outcomes. We present the factors affecting the decision-making as well as the outcomes following primary limb amputation or salvage of complex extremity injuries, with an emphasis on the various scoring systems present that endeavour to offer prognostic and therapeutic guidance to orthopaedic surgeons. Method We performed the literature search on PubMed and Embase, and collated the relevant data comprising of demographics, injury, scoring system, primary and secondary outcome metrics and complications. Results Many scoring systems, each with variable factors, have been proposed to predict limb salvage vs amputation in complex extremity injury (MESS, PSI, LSI, NISSSA, HFS-97), however the landmark LEAP trial concluded in its final analysis that they could not validate them. Whilst the scores were useful in predicting limb salvage, they were inaccurate and unreliable in predicting amputation with low sensitivities Conclusions Many scoring systems attempt to provide guidance regarding decision-making in limb salvage vs primary amputation, however the LEAP study has shown poor predictive standards of these systems. As such, there is no gold standard algorithmic approach or scoring system when making this difficult decision – instead, the poor predictors of limb salvage have been identified, and the surgeons need to be judicious and make a joint decision considering these variables and other patient factors (social, economic, and psychological status).
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