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Aims To assess current national practice in the management of severe open tibial fractures against national standards, using data collected by the Trauma and Audit Research Network. Materials and methods Demographic, injury-specific, and outcome data were obtained for all grade IIIB/C fractures admitted to Major Trauma Centres in England from October 2014 to January 2016. Results Data was available for 646 patients with recorded grade IIIB/C fractures. The male to female ratio was 2.3:1, mean age 47 years. 77% received antibiotics within 3 h of admission, 82% were debrided within 24 h. Soft tissue coverage was achieved within 72 h of admission in 71%. The amputation rate was 8.7%. 4.3% of patients required further theatre visits for infection during the index admission. The timing of antibiotics and surgery could not be correlated with returns to theatre for early infection. There were significant differences in the management and outcomes of patients aged 65 and over, with an increase in mortality and amputation rates. Conclusions Good outcomes are reported from the management of IIIB/C fractures in Major Trauma Centres in England. Overall compliance with national standards is particularly poor in the elderly. Compliance did not appear to affect rates of returning to theatre or early infection. Appropriately applied patient reported outcome measures are needed to enhance the evidence-base for management of these injuries.

Objectives This pilot study aimed to evaluate the feasibility of prospectively collecting electronic PROMs on patients being assessed as a result of musculoskeletal trauma, using a web-based application (APP), administered onto tablet and desktop computers (TCs or DCs) in the outpatient setting. Methods Following local research ethics approval, a web-based APP (TRAFIC) was developed. It consisted of a total of 12 questions (demographic information, employment, and rehabilitation status as well as quality of life (EQ5D)). The APP was viewable on TCs, with DCs being used in review cubicles when necessary with assistance from a medical professional. Eligible patients were invited to use TRAFIC during the ‘Lag period’; the time period from the patient ‘booking in’ to ‘being called’ for their appointment. An evaluation of the total time spent using the app (APP-time), was recorded as well as the total time spent in the outpatient department (CLINIC-time) for all patients recruited. CLINIC-time was also assessed for a control group of patients not utilising the APP during their outpatient assessment. Results One hundred patients were recruited for the study n = 50 males, n = 50 females with a mean age of 49.1 (± 17.6 years). All recruited patients completed the questionnaire items with a median APP-time of 5 min (range 2–118 min). The median ‘Lag period’ was 16 min. (Range 2–166 min), with a median CLINIC-time of 81 min (range 4–428). The CLINIC-time was higher than for the control group (median 67 min (range 18–242) but this was not statistically significant (Mann Whitney U test; p = 0.199). Conclusions Electronic PROMs collection in the musculoskeletal trauma outpatient clinic using a web-based APP is feasible, with the APP-time falling well within the ‘Lag period’, and no significant impact on the total time spent for the appointment.

Severe open fractures of the lower limbs are complex injuries requiring expert multidisciplinary management in appropriate orthoplastic centres. This study aimed to assess the impact of open fractures on healthcare utilisation and test the null hypotheses that there is no difference in healthcare utilisation between the year before and year after injury, and that there is no difference in healthcare utilisation in the year post-injury between patients admitted directly to an orthoplastic centre in keeping with the joint BOA/BAPRAS standards and those having initial surgery elsewhere. This retrospective cohort study utilising secure anonymised information linkage (SAIL), a novel databank of anonymised nationally pooled health records, recruited patients over 18 years of age sustaining severe open lower limb fractures managed primarily or secondarily at our centre and who had data available in the SAIL databank. 101 patients met inclusion criteria and 90 of these had records in the SAIL databank. The number of days in hospital, number of primary care attendances, number of outpatient attendances and number of emergency department attendances in the years prior and subsequent to injury were recorded. Patients sustaining open fractures had significantly different healthcare utilisation in the year after injury when compared with the year before, in terms of days spent in hospital (23.42 vs. 1.70, p = 0.000), outpatient attendances (11.98 vs. 1.05, p = 0.000), primary care attendances (29.48 vs. 11.99, p = 0.000) and emergency department presentations (0.2 vs. 0.01, p = 0.025). Patients admitted directly to orthoplastic centres had significantly fewer operations (1.78 vs. 3.31) and GP attendances (23.6 vs. 33.52) than those transferred in subsequent to initial management in other units. There is a significant increase in healthcare utilisation after open tibial fracture. Adherence to national standards minimises the impact of this on both patients and health services.

Summary Introduction The importance of long-term function and quality of life after trauma is well recognised, but gathering data is difficult. The Victoria State Trauma Registry (VSTORM) collects patient-reported outcome data after major trauma using telephone interview, following prospective enrolment. Key components of the VSTORM interview include use of the Glasgow Outcome Scale-Extended (GOS-E), collection of pre-injury demographics, use of 12-Item Short Form Health Survey (SF-12) and EQ-5D instruments as well as a pain numerical rating scale. The aim of this pilot study was to determine whether this methodology would capture clinically relevant data for a population sustaining a severe fracture associated with a wide range of potential outcomes. Methods Following ethical approval, patients with surgically managed tibial pilon fractures sustained between March 2002 and January 2010 were identified from the logbook of the senior author (IP) and contacted by post. After obtaining consent, a structured telephone interview was performed using the VSTORM questionnaire. Results Twenty-six of 45 patients consented to interview and 23/26 patients were contactable (13 male, 10 female, mean age 44 years). There were 17 Arbeitsgemeinschaft fur Osteosynthesefragen (AO) Type C fractures, six Type B and seven Grade III open injuries. The mean visual analogue scale (VAS) score for health pre-injury was 88.9 (range 50–100, median 92) versus 71.5 (range 35–100, median 75) post-injury. Seven of 18 patients in full-time employment prior to injury did not return to work. Only one patient returned to previous employment. Nine of 23 patients reported moderate – to-extreme pain interfering with work; 16/23 patients had problems with mobility; 9/23 reported problems climbing stairs; and 14/23 of patients could not resume regular social/leisure activities. Conclusions Prospective enrolment at the time of injury may improve follow-up. In those who participated, a credible range of outcomes were reported, comparable to recently published studies. This method appears efficient and acceptable to patients, and hence warrants larger-scale prospective evaluation.

Introduction Unstable pelvic fractures can be life-threatening due to catastrophic haemorrhage. Non-invasive methods of reducing and stabilising these injuries include pelvic binder application and also lower limb bandaging over a knee-flexion bolster. Both of these methods help close the pelvic ring and should tamponade bleeding. This study aimed to quantify the intra-pelvic pressure changes that occurred with 3 different manoeuvres: lower limb bandaging over a bolster; a Trauma Pelvic Orthotic Device (T-POD) pelvic binder, and a combination of both. Methods Following a pilot study with 2 soft embalmed cadavers, a formal study with 6 unembalmed cadavers was performed. For each specimen an unstable pelvic injury was created (OA/OTA 61-C1) by dividing the pelvic ring anteriorly and posteriorly. A 3–4 cm manometric water-filled balloon was placed in the retropubic space and connected to a 50 ml syringe and water manometer via a 3-way tap. A baseline pressure of 8cmH 2 O (equating to the average central venous pressure) was used for each cadaver. Steady intra-pelvic pressures (more reliably reflecting the pressures achieved following an intervention) were used in the subsequent statistical analysis, using R statistical language and Rstudio. Paired t -test or Wilcoxon’s rank sum test were used (depending on the normality of the dataset) to determine the impact of each intervention on the intra-pelvic pressure. Results The mean steady intra-pelvic pressures were significantly greater than the baseline pressure for each intervention. The binder and limb bandaging over a bolster alone increased the mean steady pelvic pressures significantly to 24 (SE = 5) (p 2 O respectively. Combining these interventions further increased the mean steady pressure to 31 (SE = 7)cmH 2 O. However, this was not significantly greater than pressures for each of the individual interventions. Discussion Both lower limb bandaging over a bolster and pelvic binder application significantly increased intra-pelvic pressure above the baseline pressure. This was further increased through combining these interventions, which could be useful clinically to augment haemorrhage control in these fractures. Conclusion Lower-limb bandaging over a bolster, and pelvic binder application, both significantly increased intra-pelvic pressures, and were greatest in combination. These findings support the use of these techniques to facilitate non-surgical haemorrhage control.

Aim The aim of this study was to describe how patients perceive their recovery following open tibial fractures using a qualitative approach. Patients and methods Following the appropriate ethical approval, adult patients with a diagnosis of open tibial fracture were recruited after completion of their surgical treatment and discharge from Morriston Hospital, a centre with orthoplastic surgical care. A purposive sampling method was employed to ensure that a range of injuries as well as clinical outcomes were included. All patients took part in an in-depth semi-structured interview, exploring aspects of their injury, treatment, rehabilitation and psychosocial and financial situations. Interviews were completed with two interviewers present and were recorded for verbatim transcription. Interview transcripts were analysed to identify items important to patients during their recovery. Results Nine patients with a mean injury to interview interval of 2.3 years were interviewed. A total of 538 items were identified and subsequently mapped onto 18 categories: pain; mobility; flexibility; temperature (effects on symptoms); fear; appearance; sleep; diet/weight; employment; social; finance; impact on others; self-care; recovery (patient perceptions of recovery); frustration; goal setting (by patients and health-care providers); and adaptation (both physical and mental). Conclusion There is a wide range of factors that our cohort found important during their recovery from open tibial fracture. Despite being considered as ‘healed’ by the medical staff, patients did not report a corresponding full recovery and return to pre-injury normality. The categories identified will enable the development of a patient-reported recovery scale to be used in lower-limb trauma.

Introduction Clinical practice should be informed by high quality evidence, of which randomised controlled trials (RCTs) are considered the gold standard. Surgical trials are inherently difficult with potential problems around clinical equipoise and participant acceptability. This is often most true with trial designs comparing operative and non-operative treatments. It is hoped that research activity can be maximised by collaborating in (a) the identification of research questions and (b) involvement in clinical trials. Development of the national research networks can be utilised to provide support for research endeavours within the orthopaedic trauma community. Aims To identify and prioritise the research questions felt to be of most importance by the orthopaedic trauma community. Research studies will be considered for questions given the highest priority. Methods A Delphi approach was used to determine consensus between the faculty members of the AOUK. A two round process was used to elicit the research questions and then to rank them in order of priority. Results 217 members of the AOUK Long Bone Faculty were asked to submit research questions, predominantly consultant orthopaedic surgeons. A 22% response rate generated 147 questions. These were collated and the most frequent 24 sent back out for ranking by mean scores. A 55% response to this second round identified 10 top questions. Literature searches for these 10 looked at current knowledge of the subject, completed and ongoing research projects. We also looked at the advantages and disadvantages of undertaking a study and the most appropriate methodology. Conclusion The response rates demonstrated a clear interest in developing a collaborative research strategy. This can be enhanced by utilising the support of the National Institute of Health Research Clinical Research Networks (NIHR CRN).

The successful management of hypovolaemic patients with unstable pelvic injuries hinges upon rapid recognition and immediate reduction of the pelvic injuries, which effects a tamponade of bleeding by decreasing the intra-pelvic volume. This has customarily been achieved by early application of an external fixator. However, recent evidence indicates that alternative methods have benefits in terms of survival and avoid unnecessary delays. Furthermore, application of a pelvic binder is noninvasive and can be easily performed in conscious patients, even in the presence of other lower limb injuries.

11 Pelvic pressure changes after a fracture: A pilot cadaveric study assessing the effect of pelvic binders and limb bandaging Rhys Morris*, Andrew Loftus, Anna Lygas, Rozina Mahmood, Ian Pallister College of Medicine, Swansea University, SA2 8PP, UK Queen Elizabeth University Hospital Birmingham, B15 2TH, UK Morriston Hospital, Swansea SA6 6NL, UK *Corresponding author. Objectives: Pelvic binders are a life-saving intervention for hypovolaemic shock following displaced pelvic fractures, thought to act through increasing intra-pelvic pressure to reduce venous bleeding. This cadaveric study assesses changes in intra-pelvic pressure with different binders augmented by bandaging the thighs to recruit the femora as levers to close the pelvis. Access to femoral vessels via an in situ binder was also assessed. Methods: Two embalmed cadavers were used with unstable pelvic injuries (OA/OTA 61-C1) created through disrupting the pelvic ring anteriorly and posteriorly. To measure intravesical pressure, which reflects intra-pelvic pressure, a supra-pubic catheter was inserted and connected to a water manometer whilst a spigot was placed in a urethral catheter to reduce leakage of fluid. The common and superficial femoral arteries were dissected in the left groin for each specimen prior to any intervention to allow inspection following binder application. A SAM pelvic sling II, Trauma Pelvic Orthotic Device (T-POD), Prometheus pelvic splint and an improvised pelvic binder were used on each cadaver, with each applied following lower limb bandaging with the knees slightly flexed. The groins were then inspected to assess if the femoral vessels were visible. Statistical analysis was performed in SPSS using a paired samples t test to determine if any difference existed between initial pelvic pressure in specimens compared to pressures with bandaging on and binders applied. Results: Bandaging the lower limbsaloneproduced a significant increase in both peak and steady mean intra-pelvic pressure, 15.69 cmH2O and 12.38 cmH2O, respectively, compared to the baseline pressure, 8.73 cmH2O (p = 0.002 and p = 0.001, respectively). Applying thepelvic binderwith thebandaging inplace increased intra-pelvic pressure compared to the baseline (peak pressure of 25.38 cmH2O (p < 0.001) and steady pressure of 15.13 cmH2O (p = 0.003)). Steadymeanpressures between bandaging alone and bandagingwith the binder appliedwere not significantly different (p = 0.09), whilst the peak pressures were significantly greater when the binder was applied (p = 0.005). The improvised binder and T-POD both required cutting to access the femoral vessels which resulted in decreasing efficacy. Conclusions: Intra-pelvic pressure was significantly increased through bandaging the lower limbs alone, and this represents a simple measure to increase intra-pelvic pressure and therefore efficacy of the binder. Access to the femoral vessels varied with binder type and represents an important consideration in polytrauma patients. http://dx.doi.org/10.1016/j.injury.2015.12.009 Poster 23 Are stainless steel elastic nails the solution to heavier children with femoral shaft fractures? Richard Hutchinson*, Sam Evans Cardiff University, United Kingdom *Corresponding author. Objectives: The use of titanium elastic intramedullary nails for the treatment of femoral shaft fractures, in children weighing 45 kg, has been questioned due to the increased rates of malunion. Our aim was to see if the mechanical properties of stainless steel elastic nails provided enough fracture stability to justify their use in heavier children. Methods: 20 synthetic paediatric-sized femoral Sawbones, with mid-shaft fractures, fixed with either titanium or stainless steel elastic nails, were tested using a four-point bending set-up. The bending stiffness and bendingmoments of the constructswere calculated at increasing loads, along with the angle of fracture deformation. From this estimates of maximum permitted body weight for each nail type could be extrapolated. Results: Stainless steel nails created significantly stiffer constructs than titanium in both the coronal and sagittal planes (p < 0.0001). Steel nails required much bigger bending moments (19.1 Nm) before loosing acceptable alignment, than titanium (14.2 Nm), in the sagittal plane (p < 0.0001). However, despite steel just out performing titanium in the coronal plane, this difference was not statistically significant. The estimated body weights extrapolated in the sagittal plane were 45 kg and 61 kg, in titanium and steel, respectively (p < 0.0001). In the coronal plane they were 42 kg and 44 kg, in titanium and steel, respectively (p = 0.457). Conclusions: As stainless steel has nearly twice the Young’s modulus of titanium, it seems logical that fractures fixedwith steel nails would be stiffer and fail at higher loads. However it is unclear why steel did not out perform titanium in the coronal plane. A theory was proposed that unequal nail slip from the insertion sites might be a contributing factor to these findings. Current evidence suggests neither stainless steel nor titanium elastic nails are suitable for stabilizing femoral shaft fractures in children 45 kg, due to risk of malunion. Further research into the use of end caps is needed to see if they provide the added stability needed in heavier children. http://dx.doi.org/10.1016/j.injury.2015.12.010 Abstracts from the 2015 Meeting of the British Trauma Society, 4th–5th November 2015 / Injury, Int. J. Care Injured 47 (2016) 293–295 295

Biomechanical testing has been a cornerstone for the development of surgical implants used in fracture stabilisation. In a multi-disciplinary collaboration complex at the University of Wales, Swansea, novel computerised clinically relevant models were developed using advanced computational engineering. In-house software (developed initially for commercial aerospace engineering), allowed accurate finite element analysis (FEA) models of the whole femur to be created, including the internal architecture of the bone, by means of linear interpolation of greyscale images from multiaxial CT scans. This allowed for modelling the changing trabecular structure and bone mineral density as seen in progressive osteoporosis. Falls from standing were modelled in a variety of directions (with and without muscle action) using analysis programmes which resulted in fractures consistent with those seen in clinical practice. By meshing implants into these models and repeating the mechanism of injury in simulation, periprosthetic fractures were also recreated. Further development with simulated physiological activities (e.g. walking and rising from sitting) along with attrition in the bone (in the boundary zones where stress concentration occurs) will allow further known modes of failure in implants to be reproduced. Robust simulation of macro and micro-scale events will allow the testing of novel new designs in simulations far more complex than conventional biomechanical testing will allow.

Supracondylar and intercondylar fractures of the distal femur occur either as insufficiency fractures in the elderly or following high-energy trauma in younger patients. These fractures comprise 4—7% of all femoral fractures and have always represented challenging fractures to treat. Many methods of fixation have been used with reportedly good results. Schatzker and Lambert concluded that the elderly patient with an osteoporotic comminuted fracture presents a significant surgical challenge which may be difficult to overcome and in some cases be beyond the surgeon’s capability. We report our experience with the T2 retrograde supracondylar nail (T2SCN Stryker, UK) which has the new feature of four distal locking screws in three different planes.

Background: Neutrophil migration into the lung is a critical, but poorly understood step in the pathogenesis of post-traumatic, acute respiratory distress syndrome (ARDS). We investigated changes in interleukin-8 (IL-8) mediated neutrophil migration and associated changes in receptor expression, of the IL-8 receptors CXCR1, the integrins CD11b/CD18 and platelet endothelial cell adhesion molecule-1 (PECAM-1) in patients sustaining major trauma. Methods: Eleven patients with major trauma, injury severity score (ISS), median 22 (range 18–41), were followed prospectively. Eleven normal volunteers were used as controls. Blood samples were obtained within 4 ± 2 h of injury, at 24 h, day 3 and day 5. Neutrophils migration was assessed by an in vitro IL-8 assay and neutrophil surface receptor expression by FACS analysis. Results: IL-8 mediated neutrophil migration was significantly increased on admission following major trauma and remained elevated for 3 days (p

The stove-in chest is a rare form of flail chest in which there is collapse of a segment of the chest wall, associated with a high immediate mortality. A 65-year-old male pedestrian was admitted with severe chest pain and dyspnoea, after being struck by a car. The initial chest radiograph demonstrated multiple right-sided rib fractures and pulmonary contusion. His gas exchange was good, and after pain relief via an epidural catheter was achieved, an intercostal drain was inserted into the right hemi-thorax. Clinically apparent deformation of the chest then occurred. A further chest radiograph confirmed the stove-in chest. The patient remained well initially, but on day 5 he deteriorated precipitously with respiratory failure, and signs of systemic sepsis. He died despite maximal ventilatory and inotropic support on the Intensive Care Unit (ICU). Post-mortem examination demonstrated congested, oedematous lungs with a right-sided empyema. The management of complex flail chest injuries requires treatment to be tailored to the individual patient. Early ventilatory support, despite good gas exchange, may have closed down the pleural space prevented the empyema. Prophylactic ventilation and possibly surgical stabilisation of the chest wall should be considered early in the course of admission, even when the conventional parameters to indicate ventilation are not met.

We describe a case of fracture–dislocation of the ankle with fixed displacement of the fibula behind the tibia (Bosworth’s fracture). The fracture was irreducible until the anterior tibio-fibular ligament was divided at operation. We believe this to be the first reported case of this fracture in which the ligament was intact. Bosworth first described this fracture in 1947 in a series of five patients and alerted readers to the poor outcome if the injury was missed [1]. The diagnosis is easily overlooked when interpreting initial radiographs, and closed reduction is usually unsuccessful. Failure to recognise the fixed dislocation of the fibula will result in inadequate treatment and a poor outcome.