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OBJECTIVE: The primary objective of this study is to assess the adherence of our department to the British Orthopaedic Association's Standards for Trauma and Orthopaedics (BOAST) guidelines for "the care of the older or frail orthopaedic trauma patient" and the results of this adherence on clinical patient outcome measures. METHODS: This was a clinical audit. All ≥65-year-olds admitted to the orthopaedic department with a fragility fracture between 8 September 2022 and 8 March 2023 with a length of stay (LOS) of >72 hours were included. Patients were stratified into hip fracture (HF) and non-hip fracture (NHF) patients. A further similar cohort of NHF admissions between 8 March and 8 May 2023 was added to the data. The adherence of both cohorts to the national guidelines was recorded. Primary outcome measures of each cohort were recorded such as LOS and patient mortality. RESULTS: Data from 70 patients was collected. HF patients adhered to the guideline 79.4% of the time (31/39 patients) compared to NHF patients at only 19.3% of the time (6/31 patients) (p<0.001). Further, on average, HF patients were seen by an orthogeriatrician 15 times compared to just five times for NHF patients during their hospital stay (p<0.001). No significant difference in LOS or in mortality at 30 days post-admission was observed. CONCLUSION: Medical orthogeriatric care is unequal despite similar LOS and mortality between both cohorts; thus, increasing orthogeriatrician input in NHF patients may lead to better patient outcomes for these patients.

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Supracondylar fractures of the distal humerus are the most common fracture around the elbow in children. A thorough initial assessment must be conducted to identify any associated neurovascular injury and carefully documented. The assessment should include a vascular examination of the radial pulse, temperature, colour and capillary refill time. A neurological examination must comment on the motor and sensory function of the radial, median and ulnar nerves. X-rays allow an evaluation of the fracture location and type, and the degree of displacement. Immobilisation in plaster is the gold standard treatment for paediatric supracondylar fracture of the humerus where the degree of displacement is within acceptable parameters. Casting should be followed by orthogonal radiographs and a repeat neurovascular assessment of the limb. Oral analgesia and safety netting information should be provided on discharge, and the child reviewed in a fracture clinic within 1 week of the injury. The British Orthopaedic Association Standards for Trauma and Orthopaedics for supracondylar fractures of the humerus in children are useful for junior orthopaedic and emergency medicine clinicians to refer to when dealing with these injuries.

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Introduction The virtual fracture clinic (VFC) can be an effective means of managing specific musculoskeletal injuries, including through protocol-driven direct discharge from the emergency department (ED) or minor injury unit (MIU). This study aimed to measure the efficiency of the VFC triage process while quantifying patient satisfaction after direct discharge from the VFC without routine face-to-face review. Methods We conducted a retrospective analysis of a prospectively collected database to ascertain VFC outcomes for 9064 patients from February 2017 to July 2018. We analysed consultant variation in VFC review and the mean time taken per patient. Patient satisfaction was investigated in 100 chronological patients initially managed via the VFC. Results The mean time to triage each patient was 74 seconds, and a mean of 503 patients was triaged each month. The telephone helpline received a mean of 0.9 calls per week. Seventy-seven percent of patients stated they were happy to be managed without a fracture clinic appointment, and 82% of patients received virtual leaflets in the ED or MIU as per protocol. The number of fracture clinic appointments was reduced by 24% as patients were discharged directly or seen instead by allied health professionals. The median patient satisfaction with VFC management was 90%, and the mean satisfaction with VFC communication was 80%. Conclusion Virtual review of fracture clinic referral enables stratification of patients according to clinical urgency and saves patients from attending unnecessary appointments. This is achieved in a patient population generally satisfied with their overall management. Our study results support the growing trend of VFCs as pivotal systems in streamlining the care of musculoskeletal injuries while adhering to British Orthopaedic Association Standards for Trauma guidelines for Fracture Clinic Services.

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The forearm is the most common site of fracture in children. At the time of initial assessment, a thorough examination and neurovascular assessment of the limb is necessary. X-rays allow evaluation of the fracture location and type, in addition to the degree of displacement. With the help of intranasal opiates, manipulation of fracture fragments can be performed in the emergency department. Immobilisation in plaster is the gold standard treatment for paediatric forearm fractures where the degree of displacement is within acceptable parameters. Manipulation and casting should be followed by orthogonal radiographs and a repeated neurovascular assessment of the limb. Oral analgesia and safety netting information should be provided on discharge and the child should be reviewed in fracture clinic within a week of the injury. This article reviews the British Orthopaedic Association Standards for Trauma and Orthopaedics for the early management of paediatric forearm fractures that do not require operative management.

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Purpose: This study aimed to audit the effects of vitamin D3 on the early functional outcomes, the incidence of nosocomial COVID-19 infection and complications in patients undergoing elective Total Knee Arthroplasty (TKA). Methods: This was a retrospective study involving patients undergoing primary unilateral TKA between January 2020 to May 2021 operated by a single surgeon using a single implant. Participants were divided into two cohorts, Deficient-vitamin D3 level <20 ng/ml and Sufficient-vitamin D3 level ≥20 ng/ml. Assessment for Knee Society Score and Oxford Knee Score (OKS) was done preoperatively and one year after TKA. Nosocomial COVID-19 infection rate, 30-day re-admissions and complications were noted during the study. Results: 235 patients were divided into 2 cohorts matched by age, gender and ASA grades. 74 patients belonged to the deficient group and 161 belonged to the sufficient group. The mean preoperative scores in the sufficient group were higher than the deficient group (OKS = 15.74 vs 12.95; KSS = 88.91vs 85.62). Similarly, the one-year postoperative scores in the sufficient group were significantly higher (OKS = 36.54 vs 35.16; KSS = 164.01 vs 161.22). A linear correlation was present between preoperative score (r = 0.273) & post-operative scores (r = 0.141) with serum vitamin D3 levels. Vitamin D3 deficient individuals had higher nosocomial COVID-19 infection rate (10.81% vs 4.96%,p = 0.16). The incidence of complications like DVT, embolism, stroke, infection and fracture were not statistically different in the two groups. Conclusion: Vitamin D positively influences the outcomes of TKA and protects against nosocomial COVID-19 infection in patients undergoing elective TKA.

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AIMS: The purpose of this study was to determine the weightbearing practice of operatively managed fragility fractures in the setting of publically funded health services in the UK and Ireland. METHODS: The Fragility Fracture Postoperative Mobilisation (FFPOM) multicentre audit included all patients aged 60 years and older undergoing surgery for a fragility fracture of the lower limb between 1 January 2019 and 30 June 2019, and 1 February 2021 and 14 March 2021. Fractures arising from high-energy transfer trauma, patients with multiple injuries, and those associated with metastatic deposits or infection were excluded. We analyzed this patient cohort to determine adherence to the British Orthopaedic Association Standard, "all surgery in the frail patient should be performed to allow full weight-bearing for activities required for daily living". RESULTS: A total of 19,557 patients (mean age 82 years (SD 9), 16,241 having a hip fracture) were included. Overall, 16,614 patients (85.0%) were instructed to perform weightbearing where required for daily living immediately postoperatively (15,543 (95.7%) hip fracture and 1,071 (32.3%) non-hip fracture patients). The median length of stay was 12.2 days (interquartile range (IQR) 7.9 to 20.0) (12.6 days (IQR 8.2 to 20.4) for hip fracture and 10.3 days (IQR 5.5 to 18.7) for non-hip fracture patients). CONCLUSION: Non-hip fracture patients experienced more postoperative weightbearing restrictions, although they had a shorter hospital stay. Patients sustaining fractures of the shaft and distal femur had a longer median length of stay than demographically similar patients who received hip fracture surgery. We have shown a significant disparity in weightbearing restrictions placed on patients with fragility fractures, despite the publication of a national guideline. Surgeons intentionally restrict postoperative weightbearing in the majority of non-hip fractures, yet are content with unrestricted weightbearing following operations for hip fractures. Cite this article: Bone Joint J 2022;104-B(8):972-979.

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Introduction The process of informed consent is vital, not only to good clinical practice and patient care, but also to avoid negligence and malpractice claims. Elective hip and knee arthroplasty numbers are increasing globally, and the British Orthopaedic Association (BOA) has endorsed standards for obtaining written consent for these procedures. Many centres in the United Kingdom and globally, use handwritten consent forms to document informed consent, leaving open the potential for missing out important procedure and risk-related information. Our study aimed to assess whether information on handwritten consent forms was compliant with BOA standards for elective arthroplasty of the hip and knee. Methods We retrospectively reviewed 70 handwritten consent forms, across theatre lists of 12 arthroplasty consultants at our elective arthroplasty centre. These included 35 forms each for hip and knee arthroplasty respectively. We compared the information on these forms to the standards prescribed by the BOA. We assessed compliance of the forms with common, less common and rare risks of hip and knee replacement, as described by the BOA. We also noted the designation of the person filling out the form (consultant, registrar or nurse practitioner) and whether this affected information on the form. We assessed the forms for legibility issues, and whether the setting (clinic/pre-operative ward) affected information on the form. Results None of the 70 forms reviewed achieved full compliance with BOA standards. When assessed for common risks of hip and knee arthroplasty, the number of compliant forms was 25.7% and 42.8%, respectively. None of the forms mentioned all rare risks of either hip or knee arthroplasty. We identified legibility issues in 12 of 70 (17.1%) forms. There was no significant difference in information written on forms filled out by consultants, registrars or nurse practitioners, or between forms filled out in the clinic versus those on the pre-operative ward. Conclusion Handwritten forms lack compliance with prescribed standards for written informed consent in elective hip and knee arthroplasty. Ideally, a pre-written consent form should be used, but with the option of adding information individually tailored to the patients' background. This ensures that good clinical practice is optimally followed, and reduces the potential risk of any litigation.

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AIMS: This study estimated trends in incidence of open fractures and the adherence to clinical standards for open fracture care in England. METHODS: Longitudinal data collected by the Trauma Audit and Research Network were used to identify 38,347 patients with open fractures, and a subgroup of 12,170 with severe open fractures of the tibia, between 2008 and 2019 in England. Incidence rates per 100,000 person-years and 95% confidence intervals were calculated. Clinical care was compared with the British Orthopaedic Association Standards for Trauma and National Major Trauma Centre audit standards. RESULTS: In total, 60% of all open fractures occurred in males; the median age was 48 years (interquartile range (IQR) 29 to 68). Between 2012 and 2019, the overall incidence in England was 6.94 per 100,000 person-years. In males, the highest incidence observed was in those aged 20 to 29 years (11.50 per 100,000 person-years); in females, incidence increased with age, peaking at 32.11/100,000 person-years at 90 years of age and over. Among those with severe open fractures of the tibia, there was a bimodal distribution in males, peaking at 20 to 29 years (3.71/100,000 person-years) and greater than 90 years of age (2.84/100,000 person-years) respectively; among females, incidence increased with age to a peak of 9.91/100,000 person years at 90 years of age and over. There has been variable improvement with time in the clinical care standards for patients with severe open fractures of the tibia. The median time to debridement was 13.0 hours (IQR 6.4 to 20.9); almost two-thirds of patients underwent definitive soft-tissue coverage within 72 hours from 2016 to 2019. CONCLUSION: This is the first time the incidence of all open fractures has been studied using data from a national audit in England. While most open fractures occurred in young males, the incidence increased with age in females to a much greater level than observed in older males. The degree of missing data in the national audit is startling, and limits the certainty of inferences drawn concerning open fracture care. Cite this article: Bone Joint J 2022;104-B(6):736-746.

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Orthopaedics has been left behind in the worldwide drive towards diversity and inclusion. In the UK, only 7% of orthopaedic consultants are female. There is growing evidence that diversity increases innovation as well as patient outcomes. This paper has reviewed the literature to identify some of the common issues affecting female surgeons in orthopaedics, and ways in which we can address them: there is a wealth of evidence documenting the differences in the journey of men and women towards a consultant role. We also look at lessons learned from research in the business sector and the military. The 'Hidden Curriculum' is out of date and needs to enter the 21st century: microaggressions in the workplace must be challenged; we need to consider more flexible training options and support trainees who wish to become pregnant; mentors, both male and female, are imperative to provide support for trainees. The world has changed, and we need to consider how we can improve diversity to stay relevant and effective. Cite this article: Bone Jt Open 2021;2-10:893-899.

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The recent coronavirus disease (COVID-19) pandemic has increased doctors' stresses at work and at home, putting them at increased risk of burnout. Considering this, we recently conducted the British Orthopaedic Association (BOA) Burnout and Wellbeing Survey which showed that, from 1298 respondents (approximately 25% of the membership of the BOA), 40% reported burnout and a further 50% were just below the threshold. The burnout rates were found to be higher in Black, Asian and minority ethnic (BAME), female and LGBTQ+ groups (45.6%) compared to white, heterosexual males (33.6% - p < 0.001) and also higher in trainees (49.1%) and associate specialists (52.1%) compared to consultants (35.7% - p < 0.001). We discuss what can be learned from the experience of the UK Armed Forces in their programme for stress management, their mental resilience training and their campaign to destigmatize mental wellbeing, that may mitigate burnout in our profession. We also put forward the case for appropriate resources to be allocated to tackling burnout in orthopaedic doctors and introduce the BOA's Wellbeing Initiative.

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Distal radius fractures account for one in five bony injuries in both primary and secondary care. These are commonly the result of a fall on outstretched hands or high-energy trauma. On assessment, clinicians should determine the mechanism of injury, associated bony or soft tissue injuries, and neurovascular symptoms. Investigations should always include radiographs to evaluate for intra-articular involvement and fracture displacement. Owing to the heterogeneous injury patterns and patient profiles, the preferred management should consider the severity of the fracture, desired functional outcome and patient comorbidities. Non-operative management in select patients can give good results, especially in older adults. Immobilisation with or without reduction forms the mainstay of non-operative treatment. Surgical management options include closed reduction and application of a cast, percutaneous K-wires, open reduction and internal fixation with plates, or external fixation. Patients should be encouraged to mobilise as soon as it is safe to do so, to prevent stiffness. Median nerve compression is the most common complication followed by tendon rupture, arthrosis and malunion. This article outlines the British Orthopaedic Association Standards for Trauma and Orthopaedics for the management of distal radius fractures.

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Managing elderly, frail patients with orthopaedic injuries, remains a challenge. Their poor bone stock and associated comorbidities makes this special cohort of patients unique in terms of their needs and the risk of developing complications. Published on line in 2019 (www.boa.ac.uk/uploads/assets/04b3091a-5398-4a3c-a01396c8194bfe16/the%20care%20of%20the%20older%20or%20frail%20orthopaedic%20trauma%20patient.pdf) the British Orthopaedic Association's Standards for Trauma focusing on the care of the older or frail patient with orthopaedic injuries, provides a contemporary guide for the holistic management of the spectrum of injury and pre-existing needs of this population.

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BACKGROUND: The Montgomery case in 2015 resulted in a pivotal change in practice, leading to a patient-centric approach for informed consent. Neck of femur (NOF) fractures are associated with a high rates perioperative morbidity and mortality. Using guidelines highlighted by the British Orthopaedic Association we performed a multi-loop audit within our department to assess the adequacy of informed consent for NOF fractures. METHODS: Two prior cycles had been performed utilising a similar framework. Prior interventions included ward posters, verbal dissemination of information at Junior Doctor's (JD) induction and amendments to the JD handbook. For the latest audit loop, a retrospective analysis of 100 patients was performed. Risk were classified as common, less common, rare and 'other' non-classifiable risks. The adequacy of informed consent was evaluated by assessing the quality and accuracy of documentation in the signed Consent Form-1s for compos mentis patients. RESULTS: Infection, bleeding risks, clots and anaesthetic risks were documented in all patients (100%). Areas of improvement included documentation of neurovascular injuries (98%), pain (75%) and altered wound healing (69%). There was no significant change in the documentation of failure of surgery (83%) and neurovascular injuries (98%). Poorly documented risk factors included mortality (21%), prosthetic dislocation (14%) and limb length discrepancy (6%). CONCLUSION: Following the latest cycle, the trust has now approved the use of 2 consent-specific stickers (for arthroplasty or fixation), amendable on a patient-to-patient basis. As part of the multi-loop process, the cycle will be repeated every year, in line with Junior Doctor rotations. Medical professionals have an ethical, moral and legal obligation to ensure they provide all information regarding surgical interventions to aid patients in making an informed decision.

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Human immunodeficiency virus is a devastating disease that ends in death. The fear that it engenders in healthworkers and patients may be out of proportion to the risks involved but an emotional response to the dangers is understandable. However, a careful study of the risks, the adoption of high standards of practice, and control of the clinical environment probably can eliminate most of the risk. There is a clear conflict of interest between the maintenance of confidentiality for the infected person and the right to information of those with whom they come into contact. Mandatory clinical testing for human immunodeficiency virus is likely to become the most contentious medicolegal issue of the next decade.

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