Background The Lancet Commission on Global Surgery established the Three Delays framework, categorising delays in accessing timely surgical care into delays in seeking care (First Delay), reaching care (Second Delay), and receiving care (Third Delay). Globally, knowledge gaps regarding delays for fracture care, and the lack of large prospective studies informed the rationale for our international observational study. We investigated delays in hospital admission as a surrogate for accessing timely fracture care and explored factors associated with delayed hospital admission. MethodsIn this prospective observational substudy of the ongoing International Orthopaedic Multicenter Study in Fracture Care (INORMUS), we enrolled patients with fracture across 49 hospitals in 18 low-income and middle-income countries, categorised into the regions of China, Africa, India, south and east Asia, and Latin America. Eligible patients were aged 18 years or older and had been admitted to a hospital within 3 months of sustaining an orthopaedic trauma. We collected demographic injury data and time to hospital admission. Our primary outcome was the number of patients with open and closed fractures who were delayed in their admission to a treating hospital. Delays for patients with open fractures were defined as being more than 2 h from the time of injury (in accordance with the Lancet Commission on Global Surgery) and for those with closed fractures as being a delay of more than 24 h. Secondary outcomes were reasons for delay for all patients with either open or closed fractures who were delayed for more than 24 h. We did logistic regression analyses to identify risk factors of delays of more than 2 h in patients with open fractures and delays of more than 24 h in patients with closed fractures. Logistic regressions were adjusted for region, age, employment, urban living, health insurance, interfacility referral, method of transportation, number of fractures, mechanism of injury, and fracture location. We further calculated adjusted relative risk (RR) from adjusted odds ratios, adjusted for the same variables. This study was registered with ClinicalTrials.gov, NCT02150980, and is ongoing. Findings Between April 3, 2014, and May 10, 2019, we enrolled 31 255 patients with fractures, with a median age of 45 years (IQR 31-62), of whom 19 937 (63•8%) were men, and 14 524 (46•5%) had lower limb fractures, making them the most common fractures. Of 5256 patients with open fractures, 3778 (71•9%) were not admitted to hospital within 2 h. Of 25 999 patients with closed fractures, 7141 (27•5%) were delayed by more than 24 h. Of all regions, Latin America had the greatest proportions of patients with delays (173 [88•7%] of 195 patients with open fractures; 426 [44•7%] of 952 with closed fractures). Among patients delayed by more than 24 h, the most common reason for delays were interfacility referrals (3755 [47•7%] of 7875) and Third Delays (cumulatively interfacility referral and delay in emergency department: 3974 [50•5%]), while Second Delays ...

The purpose of this study is to find the clinical outcome of decompression of Cauda Equina presenting late in the course of disease. There were 33 males and 17 females with average age of 48 years, ranging from 25 to 85 years. All patients presented to us with a fully developed Cauda Equina syndrome (CES). All of them presented late with mean delay of 12.2 days. Time interval between bladder and bowel dysfunction and admission to hospital varied from 1 to 35 days. The average follow-up was 34.5 months, ranging from 12 to 60 months. There was no statistically significant difference in time of delay in surgery between the recovered and non-recovered group as tested by Student's t test. But there was a statistically significant positive correlation between duration taken for total recovery and delay in surgery. Anal wink as a predictor of bladder and bowel recovery also showed statistical significance, as patients with an absence had a poorer prognosis for bladder recovery. The result of surgery in CES is not as dramatic and fast as seen after routine disc surgery. Some improvement can be expected with decompression even in those patients presenting late and results are not universally poor as previously thought. The treating physicians of such patients should be aware that the recovery in this group of patients can take an exceptionally long time and hence should involve in constant reassurance and rehabilitation of the patient. Presence of anal wink is a very good predictor of bladder and bowel recovery.

Migration of a broken wire into the hip joint or pelvis during surgery is rare, but it can cause significant complications. Retrieval can be extremely difficult and hazardous. We report 4 cases of broken Kirschner or guide wire removal around the hip joint. Two wires were inside the hip joint and two had protruded into the pelvis. The problems encountered and techniques used for retrieval are discussed.