The best hip fracture ever?

Taken from Twitter. No comment required:

Naaman orthopaedics: avoiding the complex option

Ferdinand Bol, Elisha refusing the gifts of Naaman, 1661. Rembrandthuis, Amsterdam

Most orthopaedic surgeons are renowned biblical scholars, so they will be aware that the earliest example of "keep it simple, stupid" in medicine, was probably in the Book of Kings in the Old Testament, so around 600 BC.

The story in question is that of Naaman. A recap:

Naaman was a general in the pagan Syrian army, and a confidant of the king. Unfortunately he was also a leper, a big deal then (and now). he happened to have a slave girl who was a captured Israelite, who pointed out that back where she came from - Samaria - there was a prophet who could cure him, Elisha. As nothing else had worked, Naaman went for it. He loaded up with gifts and a fancy retinue, and headed south. His first mistake was to go to the king of Israel, who got mad when Naaman quizzed him, on the reasonable grounds that he couldn't cure leprosy, so the Syrians were clearly at it.

Elisha got wind and sent a message to have Naaman visit him. So the whole convoy ended up at Elisha's place. I'll let the scripture take over here:

Elisha sent a messenger to him, saying, “Go and wash in the Jordan seven times, and your flesh shall be restored to you and be clean.” 11 But Naaman was furious and went away and said, “Behold, I thought, ‘He will surely come out to me, and stand and call on the name of the LORD his God, and wave his hand over the place, and cure the leper.’ 12 “Are not Abanah and Pharpar, the rivers of Damascus, better than all the waters of Israel? Could I not wash in them and be clean?” So he turned and went away in a rage.

I can understand it, I suppose. However, the unnamed slave girl was not impressed:

“My father, had the prophet told you to do some great thing, would you not have done it? How much more then,when he says to you, ‘Wash, and be clean’?” 

So he did, and it worked. No more leprosy. And I believe that the long term clinical outcome remained satisfactory, although I don't have the PROMS data.

Thank you for sticking with me this far. Why does this matter in orthopaedics? Well, here are a few examples:

1. The CSAW RCT showed that operating on subacromial pain was not really any better than not operating

2. The PROFHER trial, even at 5 years, showed no benefit in operating on proximal humeral fractures than not operating (I accept that there will be some self-evident exceptions to this)

3. The DRAFFT RCT found no benefit of locking plate fixation over MUA and K wires for distal radius fractures (I accept that there will be some self-evident exceptions to this, too)

4. (my favourite) Complex, expensive and fiddly revision femoral stems are no better than the unfashionable monobloc ones, which are also much easier to use. Modular may also have more implant specific complications.

I am very far from being a surgical Luddite, nor do I tend to favour conservative management - although it's a skill we need to teach more in certain areas. But...

...there is no intrinsic merit in complicating treatments, although there are many intrinsic potential risks.

The midnight hour

Even with the lousy anti-training New Deal foisted on the medical profession by the BMA and their dweebish unclinical negotiators, junior doctors - if the term is still permitted - can still end up doing a true on call, rather than shifts, and can still be called in in the middle of the night.

It seems not to be like it was however, and in many ways that's a good thing.

In the early 90's, before we had consultants in Casualty (which became A&E, now Emergency Medicine, these guys are very into semantics), patients still survived. I do welcome senior Casualty/A&E/Emergency Medicine presence, and I'm sure it's saved a few lives, though there can be a downside in terms of ownership of the case and the early decision making. But I digress.

It was correctly recognised that having a raw untutored SHO trying to resuscitate two polytraumas on his or her own, waiting for the cavalry to arrive, was not ideal. I've been there, it was pretty tough. So in my hospital we instituted the 'Trauma Bleep'. The deal was that there were three pagers held by the senior registrar in orthopaedics (me), the senior registrar in general surgery, and the senior registrar in anaesthetics (the important one, though I hate to admit it). If the bleep went off, you went straight to Casualty, no questions asked. It worked over many miles, so there was no escape. In any event, there were no mobile phones then, if you were out and thought you'd call in to see if you were really needed.

Most of the calls were not that critical, plenty of low grade stabbings that barely made it through the dermis, but there were still quite a lot of people who benefited from rapid resuscitation, airway security and all that. It coincided with the emergence of ATLS in the UK and the whole thing was really a big step forward in quality.

However, it could be bruising. My worst night I went in (a 6 mile round trip, so not too bad) at 11.30pm, got home at 2am, in again at 3am, home at 4.30am, in again at 5.30am, home for a shower at 7.30, staggering in to work for a full day starting at 8.30am. None of the cases was major trauma, but we were there, just in case.

You have to be at the bedside/trolley side to properly assess things, and it's a dying art.

I'm not recommending a return to that, but I still do on call from home, and I still go in. It's easier now as a consultant - much easier in fact, for various reasons - than it was 10 years ago and 20 years ago, when we were always having to go back in.

All this is a long winded preamble to a piece lifted in its entirety from the magnificent GomerBlog, which is mostly written by frontline clinicians. You can always tell....



On-call ophthalmologist heroically manages eye emergency from bed

DES MOINES, IA – Answering his phone in a daze at 2 AM last night, on-call ophthalmologist Reece Barnett reportedly handled a vision threatening eye emergency from the comfort of his nice warm bed.

“It was intense,” says Barnett.  “At first I was propped up on one elbow when I answered the phone. Then the emergency doc told me the patient had severe vision loss.  At that point, I sat straight up in bed with my down comforter only covering my legs.  I started getting a chill, but you gotta take these things seriously.” 

Barnett was able to listen to the patient’s history in between yawns, occasionally having the consulting doctor repeat things while he rubbed the crust from his eyes.  After several seconds of thoughtful consideration, Barnett thought it would be best to see the patient in clinic in the morning.

“This was a tough situation,” reports Barnett.  “By the end of the conversation, my sheet was all bunched up and my pillow was flat in all the wrong places.”  When asked why he elected to see the patient in the morning, Barnett replied, “By the time I get out of bed, get in my car, drive all the way to the hospital and see the patient, it will only be a few hours until morning anyway.  This is the best thing for the patient.”

At press time, Barnett was seen coordinating care for a patient with ocular trauma while wearing his eye mask.

I don't want to just pick on the eye guys, when did the on-call (and paid for it) dermatologist/breast surgeon/nearly all physicians/psychiatrist last come in at 3 in the morning?

It's bad enough trying to get a bedside visit during the day**.

**there are of course many honourable exceptions to this genuine and somewhat alarming trend

Celebrity trauma: Deniz Tek

Deniz with Iggy

In a bland era of X Factor music, you need someone like Deniz Tek. As the great man put it, talking about the onset of punk, following what he calls the 'post-hippie malaise period' of the early 70's (I remember it well):

At last, somebody getting back to basics. You compare it to maybe one or two years before, everybody’s listening to a triple album by Yes called Tales from Topographic Oceans, and if there’s anything more boring in the world, you’d have to tell me about it. That was just the epitome to us of the dreadfulness and horror of what music had become, and it was a breath of fresh air when these New York bands started blowing all that away.

There's a lot out there on this polymath, but put simply, if you like punk, metal, surf music, and the darker edges of those, like fellow Australians (sort of) The Saints playing Nights In Venice, then you'll love Tek and his awesome band, Radio Birdman. Or as this website said, he’s the “axe-wielding rock soldier commanding the legendary Radio Birdman blitzkrieg”, which is about right. Think also Stooges, MC5 (both bands were his buddies), Blue Oyster Cult, early Alice Cooper etc. Halcyon days.

But why am I writing this? Most orthopaedic surgeons these days seem to listen to Ed Sheeran or U2, who make the previously mentioned Yes seem like the Sex Pistols. The above named bands are the antidote.

Well Tek is different. When he was in his band in Australia (he's actually from Michigan) in the 70's he was studying medicine at the University of NSW. He got the textbooks out on tour.

In the 80’s he joined the US Navy, based in Hawaii and ended up as a flight surgeon organising medic evacuations, major trauma protocols and delivering emergency care all over the world, in all climates. His radio call sign actually was Ice Man.

He subsequently went on to run an Emergency Medicine service with a lot of trauma in Montana, and now combines music with painting, writing and doing EM work part time in both the US and Australia. You thought you had a complicated life?

Here he is on the professional medic/rock musician dichotomy:

"usually if it's a busy shift or there's heavy things going down I don't think of anything else until the shift's over. The other thing is you can compartmentalise and whilst I'm taking care of sick people music doesn't intrude. I think that in aviation there's a lot of value in that also. Guys that climb into the cockpit of a jet have to be able to leave their family problems behind. Y'know...the wife's goin' out with someone else or the kid's on drugs. They climb into that cockpit and if they don't do everything exactly right they're gonna die...and may be kill other people too.

One of the requisites for that is to totally compartmentalise your mind.  They screen pilots for that ability in psychological tests. If you're not that sorta person...you're just not right for the job."

Fair point - ever had the stress-inducing bleep about a family matter when you’re  in the middle of a long operation? Compartmentalise!

His website is excellent on many levels, but I particularly commend this tale of being called out to a military plane crash in Arizona. Even the Guardian likes him.

He gives career advice too:

"Any encouraging words to the young kiddies?


Work hard at whatever it is you like to do. Nothing worthwhile comes easy. And stop complaining."

Parachutes and the pelvis

*

That old saying, that an X ray is just a 2-dimensional snapshot of what actually happened, is true.

When the acetabulum fractures, the femoral head may have been halfway across the inside of the pelvis before it bounced back to where it sits on the X ray, to give one example. The injury is everything that got damaged then, not just what that 2D X ray shows. The average pilon fracture is equivalent to a small explosion in your ankle.

Most of this less obvious damage is soft tissue of course, hence the appeal of Oestern and Tscherne's slightly clunky classification of soft tissue injury, as a counterpart to Gustilo in open fractures. It seems fairly accurate, but does anyone actually use it?

A lot of pelvic ring fractures and related injuries are essentially internal dislocations of the pelvis through the symphysis and SI joints. They spring back usually, even the vertical shears to a large extent, but can you imagine what it's like at the moment of injury?

Well, imagine no more.

A big hit at the moment is Admiral William McRaven's very short and readable set of life lessons, expanded from his speech to graduates at his alma mater, the University of Austin, Texas. Rest assured, it's not a mindfulness manual. McRaven was the chief of the US Navy SEALs, and ran the operation that took out Bin Laden.

In fact it's not unlike Leo Gordon's matrix lessons, a staple of this blog.

The more general point that McRaven is illustrating with the following excerpt is that we all need help sometimes, and success in something is rarely down to ourselves alone. He describes his very tough rehab after what I think was a very bad 'open book pelvis', which happened in midair. Honestly. His description is pretty vivid...





....the book is genuinely worth reading. This particular episode confirms what we don't know from discharging people three months after injury, but one does rapidly learn doing medicolegal reports - all trauma has rehabilitation challenges, and many injuries leave you with lifetime symptoms, long after your injury has officially 'healed'.

My broken leg

At the morning trauma meeting, a closed spiral distal diaphyseal tibial shaft fracture was presented for tibial nailing. Working male, <25% displacement, good alignment, minimal shortening, no rotational deformity.

He was consented for internal fixation, with a nail. That is of course routinely referred to as informed consent, and if you're being appropriately thorough (not pedantic), the information required to make a balanced decision would have included the pros and cons of conservative treatment in a cast or brace. Traction, external fixation, plating are all in the mix, but lets stick to conservative v nailing.

Is there any published evidence worth having?

Why, yes there is.

What do you think the incidence of knee pain is after tibial nailing? Patients frequently mention it, and it can be a real problem. 10% would be OK, 20% perhaps. Well, in a very good study from Vancouver's ace trauma unit, of 56 patients at a minimum of 12 years, it was 73%.  That's knee pain, related to the nail, not fracture site pain. Of course, there are quite a few other potential problems with surgery and anaesthesia.

OK, there are still plenty of arguments for nailing, but I actually knew one surgeon who put circular frames on instead of nailing, because of anterior knee pain. A little extreme, but it makes the point. Here's the Vancouver paper.




But is there any good evidence for conservative treatment in this group of isolated fractures?

How about nearly 1000 patients treated with early functional bracing? Sarmiento's study is pretty impressive, with acceptable angulation, shortening and union rates. I won't go through it all, read it for yourself. Not the same follow up, but the point is, while each treatment has its own advantages and disadvantages, they are both valid, and should both be available to the patients. We have emphatically not 'moved beyond' tibial bracing because of our brilliance at tibial nailing.



For what it's worth, in these isolated  closed fractures, I would indeed fix those with an intact fibula - they nearly always angulate too much - and the very comminuted ones, plus the compartment syndromes. Everything else is up for discussion. Nailing is often 'fix and forget', and casting/bracing is not necessarily easy, but that's not the point. I've seen plenty of complications of nailing. It's not always in the patient's best interests.

Back to the trauma meeting. No-one seemed able to quote  a paper on either treatment. When asked "what would you have done if it was your tibia?", only one person spoke up. It was the anaesthetist, who'd had a problematic infection after orthopaedic surgery.  "Stick it in a cast" was her response.

And if consent was truly informed, a few other patients might well join her.

I always fix them in polytrauma, personally

Celebrity orthopaedics: U2

....specifically their dreaded singer Bono/Bonio. This is when he fell off his bike in Central Park in late 2014.

The talented trauma surgeon whom you can blame for Bonio's ongoing career is Dean Lorich at HSS in Manhattan. To quote the sanctimonious caterwauler himself: "The recovery has been more difficult than I thought. As I write this it is not clear that I will ever play guitar again."

Well he made it. Nice X rays, Dean

The Bonio distal humerus

An orthopaedic Christmas Carol, sort of

With a nod to Charles Dickens, this is about the ghosts of Orthopaedics Past, Orthopaedics Present and Orthopaedics Future. The reminiscences and reflections of surgeons late in their career or at retirement are a regular feature of this blog (label: wise surgeon). They really are  fascinating, and a treasure trove of useful thoughts.

This is Gordon Bannister, one of the best known British orthopods of the past 30 years, a very fine trainer and researcher, and generally a good guy, part of the Bristol centre of excellence.

He is no Luddite, but I draw your attention to a few things:

1. In the old days "senior consultant staff..had long since delegated acute trauma to their registrars. As a result, registrars acquired a wealth of experience". That's what happened to me much of the time. It doesn't happen now, which is both good and bad.

2. "At that time (the 80's) a 1:2 rota was common, occasionally tiredness ensued. The number of trainees increased whilst their experience declined". There is no way round this fact - you have to do the operations (and see the acute presentations) to get good. Most of my rotas were actually 1:3.  The promotion of the surrogate experience of 'simulated surgery' tells you how far things have gone. Note this from the former president of the RCS, Norman Williams. My view is that the New Deal has been even more damaging to training, morale and running a unit than the EWTD.

3. It was (and still should be) a lot of fun. If it consistently is not, then you may be in the wrong job.

4. I could not agree more that the demise of the true generalist to be replaced by self-anointed 'superspecialists' has been both stupid and damaging. It will be interesting to see what all the hip arthroscopy specialists will be doing in 10 years time.

Lastly, I would highlight the segment on NHS management and the conclusion. It's actually surprising how many empathetic and quality managers you encounter, but the long lasting damage wrought by the bad ones (and their political masters) is quite something.




(Thanks to BJJ News, September 2015)

Won't somebody think of the children?

It's not that often that one finds one's orthopaedic practice stimulated by The Simpsons, but here it is:

 

 They're not just little adults are they, as the anaesthetists keep telling us that, but I have to say I think it's a bit overdone - with lots of exceptions obviously. However, the subspecialisation of paediatric orthopaedics has been extended into a lot of really pretty straightforward children's trauma. In my view this has lead to a certain amount of potentially unnecessary operating.

Twenty years ago there was actually very little quality literature on fracture remodelling. There's more now, and the oldtimers' claim that you can rely on remodelling in lots of situations seems to me to be mainly true. Again, I don't mean specific potentially problematic injuries like in late teens, displaced intra-articular fractures and so on, but there has been a tendency to overcook the interventions (personal opinion, I accept). Which I think fits with the title of this must-read paper from Nottingham. (The paper references the great Mercer Rang, one of the wittiest and best writers in the history of orthopaedics, of whom more in another post)


 

Get orthopaedics out of the ITU

They don't do well

When I was starting out we saw a lot of blunt polytrauma. A lot, sometimes with several badly injured people at once. It's much rarer now, and that's one of the many reasons to concentrate it in designated trauma centres, North American style.

Then we used to fix everything as early as possible, with plenty of 12 hour all-nighter sessions, which were fun in a masochistic way. You certainly felt you'd achieved something.

A few days later, in ITU, I would often wonder why, with lots of closed fractures, the patients got septic so easily, and why it was often Gram negative septicaemia. It kept them in for ages, if it didn't kill them

Which brings me to one of the most exciting (yes, I mean that) papers that I've ever read, by John Border, from the year before he died, 1995. Border explains it better than I can, with a chronological ride through 20th century trauma surgery. I once met a Swiss AO trauma surgeon who made his money as an expert in Nissen fundoplication. An alien concept to UK surgeons, but Border was also a general surgeon -  in Buffalo - who ended up as an AO expert because he was determined to improve the management of trauma victims. He succeeded.

21 years on a lot of this is established practice and the lactate champions see it as commonplace, but back then it was revolutionary: fix fractures so they can sit up, breathe and eat. A magnificent (and beautifully written) testament to a great clinican, surgeon and researcher.

Trauma in the family

If you've ever been a patient, as a doctor you will always find it enlightening, even if it's also unpleasant. If a family member is the patient the same applies, but more unpleasant/scary than if you're the 'victim'.

Here's the experience of  a hardbitten US traumatologist from the Bronx, Paul Levin, when his own daughter was smashed up. Like Steve Krikler's AMUART (see elsewhere), it's fascinating and contains numerous lessons

AMUART - trauma from the wrong end

A few years ago the much maligned Daily Mail published a fascinating article on three urologists who all had prostate cancer themselves. I've done joint replacements on orthopaedic surgeons and other colleagues and their 'inside stories' are always worth hearing. Steve Krikler is an engaging fellow, and a very energetic educator - at conferences, editing Injury etc. Here he is describing what it's like to be smashed up in an RTA (MVA for any passing Americans). Genuinely enlightening:

They can always hit you harder

In these days of the UK New Deal and the frankly-ridiculous-and-possibly-soon-to-be-abandoned-European Working Time Directive, the young (and sometimes old) surgeon is relatively protected from this concept. Not so when I was a lad - the 24 hours of  Christmas Day 1986 comes to mind. Anyway, LG is 100% correct about this

The lactate thing and major trauma

Here's a paper which seems pragmatic. Vallier and her colleagues from MetroHealth Medical Center (US spelling) in Cleveland, Ohio - which is a big league level 1 trauma centre - looked at more than 1400 cases from a retrospective database.

My take on their findings is that an absolute figure for lactate and 'safe' operating is not the issue. A range of 2 to 4 mmol/l is OK, and it's the trend that matters. So near patient lactate testing is very handy, and most things can wait till the morning for major surgery, as opposed to essential damage control.

Your anaesthetist  may or may not be aware of this stuff, so you can educate them.

I'll put up a sensible 'lactate protocol' in due course.