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Chronic conditions, particularly HIV, TB and non-communicable diseases, represented much of the disease profile in the internal medicine department. Of the comorbidities investigated, the greatest contributor to length of stay was HIV/TB co-infection. Factors such as HIV, TB and substance use that increase length of stay cannot be impacted upon by the district hospital staff in isolation. To improve the health of communities, we require partnerships between doctors, community health providers and patients with their families. Multimorbidity was widespread, suggesting the need to include an understanding of multimorbidity, including the patient perspective, in medical education and health system reform.

Aims: To describe the epidemiology and injury severity of patients with extremity gunshot injuries in an area with a high rate of interpersonal violence. Patients and methods: This is a prospective cohort study of patients who presented with an extremity gunshot injury and were recorded as part of a trauma registry at a large tertiary care hospital in Cape Town, South Africa, between June 2015 and April 2016. Patient demographics, injury severity scores, injury patterns and referral pathways were evaluated. Results: Of 1 123 gunshot trauma admissions in ten months, 290 (25.8%) patients (91.5% males, n=269) with a median age of 26 years (IQR 13.0) presented with extremity injuries. Median injury severity score (ISS) was 4.0 (IQR 8.0). Only one-fifth of patients had an ISS of 15 or more (n=50, 17%). Upper extremity injuries were associated with a higher risk of fractures (RR 2.15, p=0.05), higher number of nerve injuries (p=0.01), and a two times higher mean ISS (p=0.01). Admissions between 7pm and 7am with limited staffing at the emergency department were twice as high as the day admissions (n=169, 57.5% versus n=79, 26.9%). Conclusion: There is a high trauma load on the emergency department and orthopaedic service due to extremity gunshot injuries. Although upper extremity gunshot wounds constituted a red flag for higher injury severity, the overall injury severity was low. Inadequate timing and selection of emergency referrals of patients with low ISS are avoidable aggravators of this burden and should be targeted to increase efficiencies in the care of these patients.

Background. Injuries inflicted by gunshot wounds (GSWs) are an immense burden on the South African (SA) healthcare system. In 2005, Allard and Burch estimated SA state hospitals treated approximately 127 000 firearm victims annually and concluded that the cost of treating an abdominal GSW was approximately USD1 467 per patient. While the annual number of GSW injuries has decreased over the past decade, an estimated 54 870 firearm-related injuries occurred in SA in 2012. No study has estimated the burden of these GSWs from an orthopaedic perspective. Objective. To estimate the burden and average cost of treating GSW victims requiring orthopaedic interventions in an SA tertiary level hospital. Methods. This retrospective study surveyed more than 1 500 orthopaedic admissions over a 12-month period (2012) at Groote Schuur Hospital, Cape Town, SA. Chart review subsequently yielded data that allowed analysis of cost, theatre time, number and type of implants, duration of admission, diagnostic imaging studies performed, blood products used, laboratory studies ordered and medications administered. Results. A total of 111 patients with an average age of 28 years (range 13 -74) were identified. Each patient was hit by an average of 1.69 bullets (range 1 -7). These patients sustained a total of 147 fractures, the majority in the lower extremities. Ninety-five patients received surgical treatment for a total of 135 procedures, with a cumulative surgical theatre time of >306 hours. Theatre costs, excluding implants, were in excess of USD94 490. Eighty of the patients received a total of 99 implants during surgery, which raised theatre costs an additional USD53 381 cumulatively, or USD667 per patient. Patients remained hospitalised for an average of 9.75 days, and total ward costs exceeded USD130 400. Individual patient costs averaged about USD2 940 (ZAR24 945) per patient. Conclusion. This study assessed the burden of orthopaedic firearm injuries in SA. It was estimated that on average, treating an orthopaedic GSW patient cost USD2 940, used just over 3 hours of theatre time per operation, and necessitated a hospital bed for an average period of 9.75 days. Improved understanding of the high incidence of orthopaedic GSWs treated in an SA tertiary care trauma centre and the costs incurred will help the state healthcare system better prioritise orthopaedic trauma funding and training opportunities, while also supporting cost-saving measures, including redirection of financial resources to primary prevention initiatives.

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Background: The clavicular hook plate is an accepted surgical procedure for distal clavicle fractures. The relationship of the characteristics of the hook plate, acromioclavicular joint and acromion morphology, and clinical outcome has remained poorly understood. We reviewed the clinical records of patients who had distal clavicle fractures with different lateral acromion angles treated using a clavicle hook plate and evaluated their clinical outcomes with respect to shoulder pain and acromial morphology. Methods: We retrospectively reviewed 102 patients with distal clavicle fractures treated with hook plates at our institution from 2010 to 2017. They were divided into four groups according to lateral acromion angle on shoulder AP view X-rays. The angle was defined as the incline angle between the superior surface of distal clavicle and the inferior facet of acromion on coronal plane. We reviewed their clinical features, including Neer's impingement sign, MRI findings, and outcomes using Japanese Orthopaedic Association Scores. The mean follow-up was 25.5 months (range, 24 to 28 months). Results: All patients in group D (large lateral acromion angle (α) > 40°, acromion coronal angle (β) < 60°) complained of postoperative symptoms. Compared to those with common lateral acromion angle, the incidence of postoperative impingement in group D was undoubtedly much higher (100%). Japanese Orthopaedic Association (JOA) scores in group D were worse at 3 months post-surgery, 3 months post plate removal, and at the last followup despite a slightly earlier removal in this group. Conclusion: Lateral acromion angle appears to be an important factor in the development of postoperative pain and worse outcomes (JOA scores) in patients treated with the hook plate. The incidence of subacromial impingement and rotator cuff lesion (RCL) increased with the α angle. Early limited mobility and removal of the implant may improve the prognosis and resolve the postoperative shoulder pain. Study design: Retrospective review, level of evidence IV.