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Background: Fractures of the distal humerus are a common fragility fracture in older adults. The purpose of this study was to systematically review the literature to produce pooled estimates of the outcomes of treatment using total elbow arthroplasty (TEA), open reduction and locking plate fixation (ORIF), hemiarthroplasty or with conservative management. Methods: A systematic review of PUBMED and EMBASE databases was conducted for studies reporting outcomes of intra-articular fractures in older adults. Data extracted included patient-reported outcome measures as well as clinical outcomes including ROM, adverse events and all-cause reoperation rates. Results: Forty-eight studies met the inclusion criteria and included 1838 acute, intra-articular distal humeral fractures. There was no clinically important difference in patient-reported pain and function measured on the Mayo Elbow Performance Score (TEA = 89.3 (SD 20.0), Hemi = 88.4 (SD 10.6), internal fixation = 85.0 (SD 14.7), non-operative = 85.1 (SD 11.0)). Discussion: Each of the treatment modalities studies resulted in a reasonable level of elbow function. The included studies were largely non-comparative and at considerable risk of bias. As elbow replacement surgery becomes centralised in the UK, there is a real need for high-quality comparative research studies to inform practice. [ABSTRACT FROM AUTHOR]

Background: Humeral shaft fractures occur frequently in older patients. The more proximal end of the shaft is prone to non-union when compared with more distal fractures. We provide an overview of several key features of this significant patient group. Method: Our institutional fracture database was searched for all cases of proximal third humeral shaft fractures in patients over 60 years of age. Retrospective evaluation of patient demographics, management, length of stay and incidence of non-union was performed. Results: 75 patients (61 female) were analysed. 33 patients were 'frail' (Clinical Frailty Scores of >4). Non-union occurred in 19 of 45 non-surgically treated fractures and in 1 of 37 cases treated surgically. Mean length of stay was 5.9 days (non-operative) and 6.6 days (operative). Proximal extension into the humeral head is common. Conclusion: Non-surgical management of proximal third humeral shaft fractures is associated with an increased risk of non-union. We detail an operative technique and case example supporting early fixation of displaced proximal third humeral shaft fractures in older patients that can be utilized for both primary and delayed fixation. In view of the significant association of non-union a well-constructed prospective cohort study with outcome assessment would be of value to further characterize this emerging injury population. Level of Evidence: Level IV, retrospective case series [ABSTRACT FROM AUTHOR]

Introduction: Indications for surgical management of displaced humeral shaft fractures are not clearly established, leading to variations in practice. The aim of this study was to determine the scale of these variations in the UK practice to help design a future national trial. Methods: An online survey was sent to all surgeon members of British Elbow and Shoulder Society to help define humeral shaft fractures, fracture displacement as well as indications for operative and non-operative management. Patient and injury related factors considered important when managing humeral shaft fractures were investigated. Results: The survey achieved a response rate of 32% (104/327). There was a lack of consensus on definitions for humeral shaft fractures and fracture displacement. A functional brace was the most common form of non-operative treatment (63%). Majority immobilise humeral shaft fractures for 4–8 weeks or until callus are visible (62%) with a similar number considering operative treatment if adequate signs of healing are not present at around 12–16 weeks. Around half of our respondents exclusively use plates with variations in preference of approach and a minority (2%) exclusively use intra-medullary nails. Conclusion: The significant variation in management of displaced humeral shaft fractures in the UK suggests a clear need to evaluate clinical and cost effectiveness through a multi-centre randomised trial. [ABSTRACT FROM AUTHOR]

Background: The majority of neck of femur (NOF) fractures are treated operatively in the United Kingdom. The literature reports the advantages of operative management for these patients. However, whilst a subset is treated non-operatively, there is currently no clear guidance for the selection and subsequent management of these patients. This study aims to explore the incidence, demographics, inpatient stay, use of imaging and outcomes of patients who have non-operatively managed NOF fractures.Methods: A 6-year retrospective review (2013-2019) of all non-operatively managed NOF fractures at a tertiary teaching hospital and major trauma centre was conducted. Electronic patient records, radiographs and National Hip Fracture Database (NHFD) data were used to obtain information. We noted demographic details, fracture classification, rationale for non-operative management, mortality, clinical frailty score (CFS), use of imaging and analgesia requirements. Patients who were repatriated or transferred to other sites for specialist surgery were excluded.Results: 3.2% (99/3132) of NOF fractures were managed non-operatively. The two commonest reasons for non-operative management were either 'comfortable mobilisation' (n = 44) or 'patient frailty/medically unwell' (n = 50). 74% (37/50) of the patients in whom operative risk was thought to outweigh benefit died within the 30 days of admission and 1-year mortality for this group was 92% (46/50). Of the "comfortable mobilisation" subgroup only 18% (8/44) of this patient subgroup subsequently required surgical intervention for failed non-operative management. The 30-day mortality for this cohort was 6.8% with a 1-year mortality rate of 25% (11/44).Conclusion: For a select group of patients whose fractures are stable enough to allow them to mobilise comfortably, non-operative management resulted in a 25% 1-year mortality rate and average length of stay of 10.1 days. This is comparable to statistics for overall NOF fracture management in the literature according to the NHFD January 2021 report. 82% of this group of patients were successfully managed without an operation indicating that there is a place for the consideration of non-operative management in a small select subgroup of hip fracture patients with minimally displaced, stable fractures. Further analysis is necessary to assess the functional outcomes of this subgroup, as well as the potential cost implications. [ABSTRACT FROM AUTHOR]

Background: Acute appendicitis (AA) is the most common general surgical emergency. Early laparoscopic appendicectomy is the gold-standard management. SARS-CoV-2 (COVID-19) brought concerns of increased perioperative mortality and spread of infection during aerosol generating procedures: as a consequence, conservative management was advised, and open appendicectomy recommended when surgery was unavoidable. This study describes the impact of the first weeks of the pandemic on the management of AA in the United Kingdom (UK). Methods: Patients 18 years or older, diagnosed clinically and/or radiologically with AA were eligible for inclusion in this prospective, multicentre cohort study. Data was collected from 23rd March 2020 (beginning of the UK Government lockdown) to 1st May 2020 and included: patient demographics, COVID status; initial management (operative and conservative); length of stay; and 30-day complications. Analysis was performed on the first 500 cases with 30-day follow-up. Results: The patient cohort consisted of 500 patients from 48 sites. The median age of this cohort was 35 [26–49.75] years and 233 (47%) of patients were female. Two hundred and seventy-one (54%) patients were initially treated conservatively; with only 26 (10%) cases progressing to an operation. Operative interventions were performed laparoscopically in 44% (93/211). Median length of hospital stay was significantly reduced in the conservatively managed group (2 [IQR 1–4] days vs. 3 [2–4], p < 0.001). At 30 days, complications were significantly higher in the operative group (p < 0.001), with no deaths in any group. Of the 159 (32%) patients tested for COVID-19 on admission, only 6 (4%) were positive. Conclusion: COVID-19 has changed the management of acute appendicitis in the UK, with non-operative management shown to be safe and effective in the short-term. Antibiotics should be considered as the first line during the pandemic and perhaps beyond. [ABSTRACT FROM AUTHOR]

Background: Humeral shaft fractures constitute around 1% of adult fractures in the UK, with an annual incidence of approximately 13 per 100,000 population. Historically, these injuries have been primarily managed non-operatively, with operative fixation reserved for specific indications. Although some recent retrospective studies have suggested there are potential benefits of operative fixation over humeral bracing, there is a deficiency in level 1 evidence to support operative management as the primary treatment for humeral shaft fractures.Methods/design: This single-centre prospective randomised controlled trial aims to recruit 70 adult patients with an isolated closed fracture of the humeral diaphysis into one of two treatment arms: operative (n = 35) or non-operative (n = 35). The operative arm will undergo open reduction and internal fixation (ORIF) of the fracture using a standard fixation technique (plate and screws). The non-operative arm will be fitted with a prefabricated humeral brace until fracture union. All patients will be followed up for 1 year post-intervention. The primary outcome measure will be the Disabilities of the Arm, Shoulder and Hand (DASH) score at 3 months post-intervention. Secondary outcome measures will include pain, treatment complications, return to work or sporting activities, shoulder and elbow range of motion, radiographic assessment, EuroQol (EQ-5D) Health Outcome score and 12-item Short Form (SF-12) Health Survey score. A health economic analysis will be performed to compare the cost implications of each treatment strategy.Discussion: This randomised controlled trial will provide level 1 evidence comparing a standard ORIF technique against functional bracing for isolated closed humeral shaft fractures. The investigators hope that the study results will assist surgeons in their decision-making when managing patients with these injuries.Trial Registration: ClinicalTrials.gov, NCT03689335 . Registered on 28 September 2018 (retrospectively). [ABSTRACT FROM AUTHOR]