Experience of managing open fractures of the lower limb at a major trauma centre

Introduction In April 2012 the John Radcliffe Hospital in Oxford became a major trauma centre (MTC). The British Orthopaedic Association and British Association of Plastic, Reconstructive and Aesthetic Surgeons joint standards for the management of open fractures of the lower limb (BOAST 4) require system-wide changes in referral practice that may be facilitated by the MTC and its associated major trauma network. Methods From 2008 to 2013 a multistep audit of compliance with BOAST 4 was conducted to assess referral patterns, timing of surgery and outcomes (surgical site infection rates), to determine changes following local intervention and the establishment of the MTC. Results Over the study period, 50 patients had soft tissue cover for an open lower limb fracture and there was a significant increase in the proportion of patients receiving definitive fixation in our centre (p=0.036). The median time from injury to soft tissue cover fell from 6.0 days to 3.5 days (p=0.051) and the median time from definitive fixation to soft tissue cover fell from 5.0 days to 2.0 days (p=0.003). The deep infection rate fell from 27% to 8% (p=0.247). However, in 2013 many patients still experienced a delay of >72 hours between injury and soft tissue cover, primarily owing to a lack of capacity for providing soft tissue cover. Conclusions Our experience may be relevant to other MTCs seeking to identify barriers to optimising the management of patients with these injuries.

Download Full-text

Management of open fractures of the lower limb during the COVID-19 pandemic: are the standards of treatment being maintained? a study from a major trauma centre in England

International Journal of Research in Orthopaedics ◽

10.18203/issn.2455-4510.intjresorthop20213232 ◽

2021 ◽

Author(s):

Rajan Choudhary ◽

Madhumita Gupta ◽

Shahidul Haq ◽

Wareth Maamoun

Keyword(s):

Soft Tissue ◽

Lower Limb ◽

Major Trauma ◽

Trauma Centre ◽

Open Fractures ◽

Trauma Service ◽

Major Trauma Centre ◽

Notable Increase ◽

Definitive Surgery ◽

Limb Fractures

Background: Coronavirus disease 2019 (COVID 19) has created an immense strain on the NHS. During the height of the pandemic, trauma services were affected by redeployment, reduced theatre capacity and staff illness, and COVID BOAST guidelines were introduced.Methods: This retrospective study aimed to evaluate the standards of management of open fractures of the lower limb at a Major Trauma Centre in the United Kingdom during the COVID-19 pandemic and compare the same with the pre-pandemic period. Patient demographics, mechanism of injury, timing and mechanism of initial debridement and definitive soft tissue and skeletal fixation were noted. Outcomes including duration of hospital stay, 30 day and 1 year mortality were also assessed.Results: There was an overall 21% reduction in admissions with open lower limb fractures during the pandemic period with a 48% reduction during the first lockdown. There was a significant reduction in time taken from Emergency Department presentation to first debridement as well as a notable increase in operating outside of regular theatre hours. There was little difference in operative technique used for skeletal or soft tissue management at initial and definitive surgery, though fewer cases were performed as a two stage procedure. There was no difference in amputation rate in the two years. Length of stay was reduced from 21 days to 17, and 30 day mortality remained the same.Conclusions: Our study shows this Major Trauma Centre was able to provide a trauma service in accordance to the BOAST4 guidelines despite the increased pressures of the COVID-19 pandemic.

Download Full-text

Lower limb paediatric trauma with bone and soft tissue loss: Ortho-plastic management and outcome in a major trauma centre

Injury ◽

10.1016/j.injury.2020.03.059 ◽

2020 ◽

Vol 51 (7) ◽

pp. 1576-1583

Author(s):

J Messner ◽

P Harwood ◽

L Johnson ◽

V Itte ◽

G Bourke ◽

...

Keyword(s):

Soft Tissue ◽

Lower Limb ◽

Major Trauma ◽

Trauma Centre ◽

Tissue Loss ◽

Paediatric Trauma ◽

Major Trauma Centre ◽

Soft Tissue Loss

Download Full-text

592 Surgical Management of Open Tibia Fractures at A Major Trauma Centre: A Review of Cases Over A One-Year Period

British Journal of Surgery ◽

10.1093/bjs/znab134.153 ◽

2021 ◽

Vol 108 (Supplement_2) ◽

Author(s):

A Khajuria

Keyword(s):

Soft Tissue ◽

Surgical Management ◽

Open Fracture ◽

Major Trauma ◽

Trauma Centre ◽

Soft Tissue Coverage ◽

Internal Stabilization ◽

Major Trauma Centre ◽

Tibia Fractures ◽

One Year

Abstract Introduction The BOAST/BAPRAS updated the open fracture guidelines in December 2017 to replace BOAST 4 Open fracture guidelines; the changes gave clearer recommendations for timing of surgery and recommendations for reducing infection rates. Method Our work retrospectively evaluates the surgical management of open tibia fractures at a Major Trauma Centre (MTC), over a one-year period in light of key standards (13,14 and 15 of the standards for open fractures). Results The vast majority of cases (93%) had definitive internal stabilization only when immediate soft tissue coverage was achievable. 90% of cases were not managed as ‘clean cases’ following the initial debridement. 50% of cases underwent definitive closure within 72 hours. The reasons for definitive closure beyond 72hours were: patients medically unwell (20%), multiple wound debridement’s (33%) and no medical or surgical reason was clearly stated (47%). Conclusions The implementation of a ‘clean surgery’ protocol following surgical debridement is essential in diminishing risk of recontamination and infection. Hence, this must be the gold standard and should be clearly documented in operation notes. The extent of availability of a joint Orthoplastic theatre list provides a key limiting step in definitive bony fixation and soft tissue coverage of open tibia fractures.

Download Full-text

The management of severe open lower limb fractures at a major trauma centre

International Journal of Surgery ◽

10.1016/j.ijsu.2013.06.430 ◽

2013 ◽

Vol 11 (8) ◽

pp. 667

Author(s):

Damien Gill ◽

Michelle Baker ◽

Scott Adams

Keyword(s):

Lower Limb ◽

Major Trauma ◽

Trauma Centre ◽

Lower Limb Fractures ◽

Major Trauma Centre ◽

Limb Fractures

Download Full-text

The sensitivity of pre-hospital and in-hospital tools for the identification of major trauma patients presenting to a major trauma centre.

Journal of The Royal Naval Medical Service ◽

10.1136/jrnms-99-16 ◽

2013 ◽

Vol 99 (1) ◽

pp. 16-19

Author(s):

D Potter ◽

A Kehoe ◽

JE Smith

Keyword(s):

Major Trauma ◽

Injury Severity ◽

Trauma Centre ◽

Research Network ◽

Trauma Network ◽

Trauma Patients ◽

Major Trauma Centre ◽

Injury Assessment ◽

Trauma Response ◽

Retrospective Database

AbstractThe identification of major trauma patients before arrival in hospital allows the activation of an appropriate trauma response. The Wessex triage tool (WTT) uses a combination of anatomical injury assessment and physiological criteria to identify patients with major trauma suitable for triage direct to a major trauma centre (MTC), and has been adopted by the South-West Peninsula Trauma Network (PTN). A retrospective database review, using the Trauma Audit Research Network (TARN) database, was undertaken to identify a population of patients presenting to Derriford Hospital with an injury severity score (ISS) > 15. The WTT was then applied to this population to identify the sensitivity of the tool. The sensitivity of the WTT at identifying patients with an ISS>15 was 53%. One of the reasons for this finding was that elderly patients who are defined as having major trauma due to the nature of their injuries, but who did not have a mechanism to suggest they had sustained major trauma (such as a fall from standing height), were not identified by these triage tools. The implications of this are discussed.

Download Full-text

Impact of the COVID-19 pandemic on the management of open fractures in a major trauma centre

Journal of Clinical Orthopaedics and Trauma ◽

10.1016/j.jcot.2021.101509 ◽

2021 ◽

pp. 101509

Author(s):

Patrick O'Hagan ◽

Isabella Drummond ◽

David Lin ◽

Keng Suan Khor ◽

Alexandros Vris ◽

...

Keyword(s):

Major Trauma ◽

Trauma Centre ◽

Open Fractures ◽

Major Trauma Centre

Download Full-text

1416 Trauma Laparotomy: Experience of a Newly Established Major Trauma Centre in Northern Ireland

British Journal of Surgery ◽

10.1093/bjs/znab259.532 ◽

2021 ◽

Vol 108 (Supplement_6) ◽

Author(s):

F Lee ◽

B Bashabayev ◽

S Yoong

Keyword(s):

Northern Ireland ◽

Royal Victoria Hospital ◽

Major Trauma ◽

Trauma Centre ◽

Trauma Network ◽

Final Report ◽

Major Trauma Centre ◽

The Mean ◽

One Year ◽

Mean Time

Abstract Aim The aim of this study was to assess the perioperative pathway and outcomes of trauma laparotomy during a one-year period in a newly established Major Trauma Centre in Northern Ireland. Method Retrospective review of a trauma registry undertaken at the Belfast Royal Victoria Hospital between August 2019 and August 2020. Results During this one-year period, there were a total of 17 trauma laparotomies, with a female-to-male ratio of 6:11, and a mean age of 38.9 years. 15 of 17 cases were due to blunt trauma, with only 2 cases of penetrating trauma. Of trauma laparotomies, 8 were performed during day-time hours (0801-1800), 4 during evening-hours (1801-0000), and 5 during night-time hours (0001-0800). One perioperative death was recorded. The mean time to CT from arrival to ED was 34 minutes (national target of 30 minutes). The mean time until final report was 477 minutes (national target of < 24 hours). The decision to proceed to trauma laparotomy was made prior to the final report in 9 cases. The mean length of inpatient stay for trauma laparotomy patients was 23.3 days, with a mean of 8.9 days spent in critical care. Conclusions This review provides an overview of provision of care for patients who underwent trauma laparotomies in Royal Victoria Hospital MTC and identifies areas for improvement. We plan to prospectively review outcomes following the opening of the Major Trauma Ward on 7th September 2020 and the implementation of the Northern Ireland Major Trauma Network Bypass protocol on 26th October 2020.

Download Full-text

Injured patients who would benefit from expedited major trauma centre care: a consensus-based definition for the United Kingdom

British Paramedic Journal ◽

10.29045/14784726.2021.12.6.3.7 ◽

2021 ◽

Vol 6 (3) ◽

pp. 7-14

Author(s):

Gordon Fuller ◽

Samuel Keating ◽

Janette Turner ◽

Josh Miller ◽

Chris Holt ◽

...

Keyword(s):

United Kingdom ◽

Major Trauma ◽

Trauma Centre ◽

Research Network ◽

Future Research ◽

Trauma Network ◽

Reference Standard ◽

The United Kingdom ◽

Major Trauma Centre ◽

The Right

Introduction: Despite the importance of treating the ‘right patient in the right place at the right time’, there is no gold standard for defining which patients should receive expedited major trauma centre (MTC) care. This study aimed to define a reference standard applicable to the United Kingdom (UK) National Health Service major trauma networks.Methods: A one-day facilitated roundtable expert consensus meeting was conducted at the University of Sheffield, UK, in September 2019. An expert panel of 17 clinicians was purposively sampled, representing all specialities relevant to major trauma management. A consultation process was subsequently held using focus groups with Public and Patient Involvement (PPI) representatives to review and confirm the proposed reference standard.Results: Four reference standard domains were identified, comprising: need for critical interventions; presence of significant individual anatomical injuries; burden of multiple minor injuries; and important patient attributes. Specific criteria were defined for each domain. PPI consultation confirmed all aspects of the reference standard. A coding algorithm to allow operationalisation in Trauma Audit and Research Network data was also formulated, allowing classification of any case submitted to their database for future research.Conclusions: This reference standard defines which patients would benefit from expedited MTC care. It could be used as the target for future pre-hospital injury triage tools, for setting best practice tariffs for trauma care reimbursement and to evaluate trauma network performance. Future research is recommended to compare patient characteristics, management and outcomes of the proposed definition with previously established reference standards.

Download Full-text