20 Adolescent and caregiver perspectives on living with a limb fracture: A qualitative study

Primary Subject area Emergency Medicine - Paediatric Background Fractures occur in up to half of children by age 16 years. After initial emergency care for a fracture, function is universally impaired in children, and impacts extend to the immediate family. Knowledge of expected functional limitations is key to providing proper discharge instructions and anticipatory guidance to families. Objectives Our study objectives were to understand: 1) how adolescents (12-17 years) describe the functional impact of fractures on their lives; 2) how adolescents’ reports of their experiences compare to those of their caregivers; and 3) the impact of the fracture on the family unit. Design/Methods We conducted individual, semi-structured interviews from June 2019 to November 2020 with adolescents and their caregivers, 7-14 days following their initial visit to a pediatric emergency department. We utilized qualitative content analysis methodology. Recruitment proceeded until thematic saturation was achieved. Coding and analysis were concurrent with recruitment and interviews. A secondary coder reviewed 40% of the transcripts, and the coding team met regularly to discuss the coding framework and key themes. The interview script was modified in an iterative process, to reflect emerging themes. Results We completed a total of 29 interviews. The most commonly affected functions were: a) showering and hygiene (which required the most caregiver support); b) sleep variability (due to pain and cast-related discomfort); and c) exclusion from sports/activities. Many adolescents experienced disruptions to social activities and gatherings. Adolescents valued independence and often chose to take more time to complete a task to preserve this, regardless of inconvenience. Both adolescents and caregivers reported feelings of frustration as a result of day-to-day impacts imposed by the injury. Generally, caregivers’ perspectives were in keeping with the experiences that adolescents described for themselves. Notable family impacts included what we described as ‘sibling burden’ or conflicts that arose when a sibling had to take on extra chores/tasks. Conclusion These themes highlight an opportunity to better tailor discharge instructions for adolescents with fractures. Key messages include: 1) expect pain and impaired sleep, especially in the first few days; 2) allow extra time to complete tasks independently, especially for grooming and hygiene; 3) consider family impact, especially sibling burden; 4) prepare for changes in activities and social dynamics; and 5) frustration is normal, for both adolescents and caregivers. Future work can focus on developing a novel, family-informed tool to assess functional outcomes following injury.

Translation, Reliability and Validity of the Spanish Version of the Modified New Mobility Score (NMS-ES)

The New Mobility Score (NMS) is an easy to administer self-report measure of functional ability, and is used worldwide as a hip fracture (HF) score, but a Spanish version does not exist. The aim of the study is to translate NMS into Spanish, and to measure its inter-rater reliability, internal consistency, and concurrent validity in a sample of Spanish speaking patients with HF. A reliability and validity study with a sample of 60 adults, 65 years or older (46 women and 14 men; mean age 81.7 years) with a hip fracture admitted consecutively to the acute trauma service of the Health Campus Hospital of Granada. The participants were interviewed during the first week after surgery by an occupational therapist or a physiotherapist. The statistical test used for analysis were: Cronbach’s α coefficient, McNemar–Bowker test, Bland–Altman plot, Spearman´s Rho, and Mann–Whitney U test. The Cronbach’s α coefficient was 0.90. No inter-rater systematic differences were found. We noted significant associations between the Spanish Version of the Modified New Mobility Score (NMS-ES) and selected health outcomes: Age, cognition, pre-fracture function, and basic mobility. The NMS-ES is a reliable and valid instrument to assess pre-injury functional levels for patients with HF in Spanish speaking countries.

A health care record review of early mobility activities after fragility hip fracture: Utilizing the French systematic method to inform future interventions

Background A fragility hip fracture is a serious injury in older adults. Following a fragility fracture, a large percentage of patients are unable to regain their pre-fracture level of mobility. There are several international guidelines recommending early mobility after surgery. We do not know the utilization of these early mobility recommendations by health care providers within our institution. An evidence to practice gap occurs when there is a failure to implement best practices. Utilization of a systematic method allows for a strategic approach to assessment of an evidence to practice gap. A recent publication of quality standards in Ontario provides an opportunity for a local needs assessment of potential evidence to practice gaps. The aim of this project was to identify evidence to practice gaps in health care provider implementation of recommendations for early mobility after fragility hip fracture surgery.Methods A retrospective chart review was performed to document the rates of early mobility activities during the first five days after hip fracture surgery at a large tertiary centre in Toronto, Ontario. Patients with cognitive impairment were included.Results Early mobility activities in this older adult population are initiated in the first five days after surgery to varying degrees. Between 11% - 50% of patients are not participating in early mobility activities, thereby not meeting recommendations. Those with low pre-fracture function and cognitive impairment have lower rates of participation when compared to those with a high pre-fracture function and no cognitive impairment.Conclusions The chart review has identified a paucity of contextual information which may influence health care providers’ behaviours related to early mobility. The chart audit is limited in its ability to assess the systems issues, which may have an influence on the health care provider behaviour. Considering the lack of information in these areas, we have identified that further work is required to explore factors which may be having an impact on the health care provider’s ability to engage the patients in early mobility activities.

A health care record review of early mobility activities after fragility hip fracture: Utilizing the French systematic method to inform future interventions

Background A fragility hip fracture is a serious injury in older adults. Following a fragility fracture, a large percentage of patients are unable to regain their pre-fracture level of mobility. There are several international guidelines recommending early mobility after surgery. We do not know the utilization of these early mobility recommendations by health care providers within our institution. An evidence to practice gap occurs when there is a failure to implement best practices. Utilization of a systematic method allows for a strategic approach to assessment of an evidence to practice gap. A recent publication of quality standards in Ontario provides an opportunity for a local needs assessment of potential evidence to practice gaps. Objective To identify if there is an evidence to practice gap in health care provider implementation of recommendations for early mobility after fragility hip fracture surgery. Methods A retrospective chart review was performed to document the rates of early mobility activities during the first five days after hip fracture surgery at a large tertiary centre in Toronto, Ontario. Patients with cognitive impairment were included. Results Early mobility activities in this older adult population are initiated in the first five days after surgery to varying degrees. Between 11% - 50% of patients are not participating in early mobility activities, thereby not meeting recommendations. Those with low pre-fracture function and cognitive impairment have lower rates of participation when compared to those with a high pre-fracture function and no cognitive impairment. Conclusions The chart review has identified a paucity of contextual information which may influence health care providers’ behaviours related to early mobility. The chart audit is limited in its ability to assess the systems issues, which may have an influence on the health care provider behaviour. Considering the lack of information in these areas, we have identified that further work is required to explore factors which may be having an impact on the health care provider’s ability to engage the patients in early mobility activities.

RESILIENCY PHENOTYPES FOLLOWING HIP FRACTURE IN OLDER ADULTS

Defining common patterns of recovery after an acute health stressor (resiliency phenotypes) has clinical and research implications. We examined groups of patients with similar recovery patterns across 10 outcomes following hip fracture to determine the most important predictors of resiliency group membership. This study is a secondary analysis of three prospective cohort studies. Participants, community-dwelling adults aged >65 with recent surgical repair of a hip fracture (n=541), were recruited from eight hospitals near Baltimore and followed for up to one year. Self-reported function and activity measures were collected using validated scales at baseline, 2, 6, and 12 months. Physical performance tests were administered at all follow-up visits. Stressor characteristics, co-morbidities, psychosocial and environmental factors were collected at baseline, and latent class profile analysis was used to identify resiliency phenotypes and logistic regression models to identify associated factors. Three resiliency phenotypes had similar patterns across the 10 outcome measures and were defined as “high resilience” (n=163, 30.1%), “medium resilience” (n=242, 44.7%), and “low resilience” (n=136, 25.2%). Recovery trajectories for outcome measures were plotted for each resiliency group. Self-reported pre-fracture function was by far the strongest predictor of resilience group membership (AUC 0.84). Demographic factors, co-morbidities, stressor characteristics, environmental factors, and psychosocial characteristics were less predictive, but several factors remained significant in a fully adjusted model (AUC 0.88). These three resiliency phenotypes have immediate utility for clinical decision-making. They can be measured in future studies with a more parsimonious set of variables, and may prove useful for understanding mediators of physical resilience.

Regaining Versus Not Regaining Function Following Hip Fracture—A Descriptive Study

The aim of this study was to study the prevalence of patients who did not regain pre-fracture basic mobility status (PF-BMS) at a task-specific level at discharge with 6-month follow-up. Furthermore, the objective was to make a comparative description between patients who did and did not regain PF-BMS measured with the Cumulated Ambulation Score (CAS). A cross-sectional study with follow-up at discharge and 6 months was performed from June 2015 to November 2017. Inclusion criteria: all patients ≥65 years admitted with first-time hip fracture. In all, 235 patients were included in the analyses at discharge (76% female, median age 85 (83–87)) and 59 patients at 6 months (48% female, median age 82 (75–88)). At discharge, getting in/out of bed had the highest prevalence of non-regained ability. At 6 months this was the case for getting in/out of bed and walking. At discharge, significant between-group differences were found regarding age, pre-fracture function (PFF), dementia, pre-fracture residence (PFR), comorbidity, and length of stay (LOS). At follow-up, significant differences in PFF, PFR, discharge destination (DD) and residence at 3 months after discharge (RES-3) were found. Getting in/out of bed was the most difficult task to regain both during admission and long term.

Effect of Malunited Midshaft Clavicular Fractures on Shoulder Function

Background and Purpose. Displaced middle third clavicle fractures are traditionally treated non-operatively and heal with residual deformity. Few studies assessed treatment success by using patient-oriented outcome measures or objective muscle strength testing. The purpose of our study was to determine whether clavicle malunion affects functional results. Methods. Union was documented in 25 patients who were treated conservatively due to a displaced mid shaft clavicle fracture. Ten had significant malunion. Patients were examined at least 12 months following the fracture. Function was assessed by DASH and UCLA questionnaires. Clinical assessment included Range of Motion (ROM) measurement, manual and isokinetic muscle strength testing. Healthy shoulder served as a control. Results. Mean follow up time was 38 months. The mean DASH score was 9, mean UCLA score was 31.7. Range of motion was preserved—less than 6° side-to-side difference. Abduction strength reduction in the involved side amounted to 7%. No correlation was found between radiographic malunion and the functional results. Interpretation. Displaced healed middle clavicle fractures result in satisfactory functional results. The average deficits detected in strength and ROM were within the normal limits compared to the non-injured side. Radiographic healing position had no effect on functional outcome.