Bone healing



Summmary Clinical Audit Report Template[pic]

|Registration Number |Distal Radius fractures manipulation in A&E |

|CA | |

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|Audit Lead |Viktoras Kubaitis | |1st Cycle/Re-Audit |

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|Job Title |Registrar | | |

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|Department |Orthopaedics | | |

|SUMMARY: | |

|What was done? |

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|We found 20 cases were distal radius fracture was treated by manipulation during 3 month period in our A&E. We investigated notes and radiographs of patients and |

|finally we contacted patients by phone. We compared allowance angles with post-manipulation angles achieved in A&E. |

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|Why was it done? |

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|Manipulations for fractures and dislocations radiological results in our A&E were found not satisfactory in comparing with our days literature and orthopaedics |

|understanding. |

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|What the results show? |

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|The post-manipulation x-rays shows that angles of distal radius are worse comparing with allowance in most cases. The results of our A&E distal radius |

|manipulation has to be improved. |

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|What improvements have been made? |

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|Presentation for A&E colleagues ,Plaster making technique, with more attention to distal radius fractures manipulations and conservative treatment was prepared. |

|The poster on A&E wall with distal radius geometrical anatomical and allowance angles was made. |

DETAIL:

|PROJECT AIMS / OBJECTIVE: | |

|What were the aims and objectives of the audit |

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|Manipulations for fractures and dislocations radiological results in our A&E were found being ambiguous and are not satisfactory in comparing with our days |

|literature and orthopaedics understanding. Some of patients need repeated MUA in fracture clinic in next morning and it makes questions for patients. It is |

|potential situation for time and resources waist and complains from patient side. |

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|METHODOLOGY: | |

|Audit criteria and standards, Source of standards e.g. NICE |

|Data collection e.g. prospective or retrospective |

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|IT department found all cases were manipulations were done in A&E using special coding system (Code number 11 and 27) from 01/11/2015 till 30/01/2016. The biggest|

|group in these manipulations were found manipulations for distal radius fractures. We investigated only manipulations which were done for distal radius fractures.|

|Other types of procedures in A&E coded by 11 and 27 were left out of interest due to lack of cases and diversity. We investigated notes and radiographs of |

|patients and finally we contacted patients by phone. We retrospectively found all 21 cases were distal radius fracture was treated by manipulation during 3 month |

|period in our A&E. One lady has not got post MUA x-rays and was excluded from Audit statistics. |

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|We used manipulation results allowance as our standard: |

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|Dorsal tilt / degrees |

|Radial inclination / degrees |

|Shortening / mm |

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|Anatomical angulations |

|11 |

|22 |

|0 |

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|Before MUA |

|-19 |

|15.5 |

|4.5 |

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|Theoretical allowance |

|0 |

|15 |

|5 |

| |

|After the MUA |

|-5.4 |

|19 |

|2 |

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|Our sources and references: |

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|Review of Orthopaedics. Mark D. Miller. Fifths edition. Page No 410-411; |

|Review of Orthopaedics. Mark D. Miller. Sixth edition. Page No 523; |

|AAOS Textbook of Orthopaedics, Page No 560-561; |

|AAOS Guideline on The Treatment of Distal Radius Fractures; |

|Focus On Distal radius fracture: current concepts and management. Bone & Joint Journal. 2013; |

|Orthobullets web page |

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|RESULTS: | |

|What did the results show? Highlight any concerns or positives and discussion points. Highlight any need for changes in practice. |

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|We were able to evaluate 14 notes out of 21. It is difficult to understand who done procedures and what kind of anaesthetic was used during the procedure. |

|Doctors’ signatures and hand writing could be more eligible. |

|18 patients out of 21 were female. The medium age in our group was 67 (17-97). |

|We evaluated radiographs of the patients. One patient has not post manipulation x-rays and patient was excluded from Audit. Anatomical patterns of fractures were |

|very not even. We used Frykman classification which we found simplest and reproducible. |

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|There were 3 fractures involving more proximal part of ulna (more proximal than just ulnar styloid fracture) which are apparently is more unstable type of distal |

|radius fractures something in between distal radius fractures and radius-ulna methaphysial forearm fractures. |

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|We evaluated how much degenerative changes were before trauma. 8 wrists out of 21 had already 4 degree of degenerative osteoarthritis. 6 of them have mostly STT |

|changes. Comminution and complexity of the fracture and Frykman type 6-7-8 were associated with 4th degree of osteoarthritis in the wrist. |

|One wrist had mal-union of the ulnar styloid after previous fracture. One wrist had geometrical changes post previous CL ligament tear. We found a scaphoind |

|non-union in one wrist prior to trauma. |

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|We evaluated how much radius styloid was inclined before procedure. Normal anatomical inclination is 22. Medium inclination after injury was 15.5 degrees (-7.7 to|

|25.5). |

|Articular level of radius and ulna has to be usually in the same level. Medium shortening of the radius after the injury was 4.5 mm (0-11). There was ulna minus |

|in one wrist. |

|Normally radius articular surface of the radius is directed volary +7 to +11 degrees. Medium volar angulation after the trauma was -19 degrees (-1.7 to -44). |

|11 fractures out of 21 had distal fragment cominution. 10 out of 21 had inter-framental cominution. 9 out of 21 had dorsal cominution. |

|11 out from 21 fractures were associated with distal ulna fracture. No one patient was investigated by US for possibility of TFSS complex injury. |

|Two fractures were with 2 mm articular step. One of them was operated on. Four fractures had less than 1 mm articular step. |

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|We measured radial inclination post procedure. Medium inclination was 19 degrees (0.9 to 31). Inclination difference after the procedure was found 4 degrees. |

|Inclination was even worse after the procedure in 4 cases out of 20. There was no change in inclination in two cases. |

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|There was medium 2 mm (0-8 mm) shortening after the procedure. The radius length was not achieved in 13 out of 19 cases. The shortening improvement after the |

|procedure was 1.6 mm. It was worse in 2 cases. There was no difference in 6 cases. |

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|The medium volar angulation after the procedure was -5.4 degrees. 17 cases out of 20 was did not achieved anatomical volar angulation (-20.4 to 16 degrees). The |

|reduction allowance is 0 degrees Only 3 cases out of 20 were reduced acceptable reaching allowance limit. Medium volar angulation improvement was 13 degrees ( 0 |

|to 33 degrees). Volar angulation was not improved in one and was even worse in 2 cases out of 20. |

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|We have tried to contact patients on phone and to evaluate clinical result after 6 month after the treatment. 6 patients have not answered the phone at all or |

|were not willing to speak, or we have not the number of the phone. 3 patients were too confused to speak on the phone. |

|The best analgesia during the MUA was found with sedation with Midasolam. But there were only two patients with that kind of analgesia and analgesia is more |

|risky. Haematoma block was almost as comfortable as Midasolam sedation. There was one case when patient suffered from pain but most likely the injection was made |

|not in to the fracture side directly. The highest VAS Score (Visual Analog Scale) was with Enthanox gas - 6.67 points. |

|No |Source of guidance or Standard |Audit Standard |Target |Result |Total (n)|

| | | |(%) |(%) | |

|1. |Postgraduate Orthopaedics. Second Edition |Allowance of deformity after the MUA|100 |10 |20 |

| |Review of Orthopaedics. Mark D. Miller. Fifths edition |Dorsal tilt ≥0o | | | |

| |Orthobullets web page |Radial inclination ≥15o | | | |

| |AAOS Textbook of Orthopaedics |Shortening ≤5 mm | | | |

| |AAOS Guideline on The Treatment of Distal Radius Fractures |Radial height ˃8 | | | |

| |Focus On Distal radius fracture: current concepts and management. Bone & |Articular step-off ≤2 mm | | | |

| |Joint Journal. 2013 |Lateral displacement 10 mm | | | |

|2. |The closed Treatment of Common Fractures. Sir John Charnley |Back slab has to have |100 |40 |20 |

| | |volar angulation 15-25o. | | | |

| | |Less than normal allows secondary | | | |

| | |displacement. Too big disturbs blood| | | |

| | |circulation | | | |

|3. |The closed Treatment of Common Fractures. Sir John Charnley |Back slabs summit has to be over the|100 |75 |20 |

| | |fracture and not over the wrist – | | | |

| | |proper three point fixation | | | |

| | |technique | | | |

|4. |The closed Treatment of Common Fractures. Sir John Charnley |Cast has to cover properly radius, |100 |35 |20 |

| | |not the ulna on AP | | | |

|5. |The closed Treatment of Common Fractures. Sir John Charnley |Cast has to be 3-5 mm thick. Too |100 |30 |20 |

| | |thin would be unstable. Too thick | | | |

| | |would be too bulky and uncomfortable| | | |

|6. |Injury. 2006 Mar;37(3):259-68. Epub 2006 Jan 18. |Too much wool padding can be reason |100 |60 |20 |

| |Re-displacement of paediatric forearm fractures: role of plaster moulding|for secondary displacement post MUA.| | | |

| |and padding. |Back slab padding index has to be | | | |

| |Bhatia M, Housden PH. |(PI ≤ 0.3) | | | |

|7. |Chess et al. (1994).  Chess DG, Hyndman JC, Leahey JL, Brown DC, Sinclair|CI (≥0.84) |100 |70 |20 |

| |AM. Short arm plaster cast for distal pediatric forearm fractures. J | | | | |

| |Pediatr Orthop. 1994;14:211–3 | | | | |

|8. |Common sense |MUA has to be once. Some cases were |100 |80 |20 |

| | |manipulated on second time | | | |

|We have tried to contact patients on phone and to evaluate clinical result after 6 month after the treatment. 6 patients have not answered the phone at all or |

|were not willing to speak, or we have not the number of the phone. 3 patients were too confused to speak on the phone. |

|The best analgesia during the MUA was found with sedation with Midasolam. But there were only two patients with that kind of analgesia and analgesia is more |

|risky. Haematoma block was almost as comfortable as Midasolam sedation. There was one case when patient suffered from pain but most likely the injection was made |

|not in to the fracture side directly. The highest VAS Score (Visual Analog Scale) was with Enthanox gas - 6.67 points. |

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|Patients feel most comfortable on Sedation by Midasolam. Haematoma block is safe and easier procedure than Sedation and even the same comfortable as with |

|Midasolam. The patient can obey commands during the MUA on Haematoma block. Manipulation under Enthanox gas is painful and patient cannot relax properly. |

|Patients |Type of pain relief during the MUA |VAS average |

|2 |Sedation with Midasolam IV |2.0 (0-4) |

|7 |Haematoma block local anaesthetic |2.14 (0-9) |

|3 |Enthanox gas |6.67 (5-8) |

|The final clinical - functional result was found very good 8.33 points out of 10 after the 6 month post trauma. Results of fractures distal radius were verbally |

|compared with the function of the opposite healthy wrist. As usual with distal radius fractures final clinical results mismatch radiological pictures. Even |

|obviously displaced fractures can heal up with satisfactory function. Nobody knows how much posttraumatic osteoarthritis can be found in far distant period in |

|mal-united cases. |

|There is no exact correlation between radiological angles after the MUA and final clinical results but MUA quality has to be evaluated by improved articular |

|angles. Allowance after the deformity improvement is described in literature obscure but our Audit shows that results of our A&E has to be improved. |

|OUTCOME: | |

|What recommendations can be made from the outcome of the project? |

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|To apply more vigorous ulnar and volar deviation during the procedure and match your results with allowance. |

|Distal ulna – radius methaphysial fractures are unstable and needs surgical stabilisation. |

|US test for TFCC possible injury has to be used more often. |

|To avoid Enthanox gas as single pain relieve tool for MUA. |

|IMPROVEMENTS ACHIEVED: | |

|State any improvements achieved already, unless listed on action plan overleaf. |

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|The main criteria for distal radius manipulation evaluation were found in different orthopaedic literature. The anatomical angles, allowance of post-manipulation |

|angles and results of A&E were discussed and agreed in Audit meeting. Presentation for A&E colleagues ,Plaster making technique, with more attention to distal |

|radius fractures manipulations and conservative treatment was prepared. The poster on A&E wall with distal radius geometrical anatomical and allowance angles was |

|made. |

Do You Intend Re-Audit Yes X No .... Action Plan completed Yes X No ....

|KEY (Change Status) |

|Recommendation agreed but not yet actioned |

|Action in progress |

|Recommendation fully implemented |

|Recommendation never actioned (please state reasons) |

|Other (please provide supporting information) |

Clinical Audit Action Plan

|Project Title |Distal Radius fractures manipulation in A&E |

|Action Plan Lead |Name: Viktoras Kubaitis |Title: Mr. |Contact: 07580598952 |

| | | |Viktoras.kubaitis@ |

|Group/Meeting Responsible for Monitoring Action Plan |07/06/2016 |

|Recommendation |Actions Required |Action by Date |Person Responsible |Changes in Practice |Change Status |

|To avoid Enthanox gas as single pain relieve |Use Enthanox gas only as additional relieve during|01/10/2016 |A&E doctors | | |

|tool for MUA. |manipulation | | | | |

|Distal ulna – radius methaphysial fractures are|Recognise unstable methaphysial fractures and |01/10/2016 |Orthopaedics | | |

|unstable and needs surgical stabilisation |segregate them from common distal radius fractures| | | | |

|US test for TFCC possible injury has to be used|Suspect possible TFCC injury and refer pt to be |01/10/2016 |Orthopaedics | | |

|more often |tested by US | | | | |

|Comments | |

| |Action plan |

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| |To make presentation for A&E colleagues ,,Plaster making technique,, with more attention to distal radius fractures manipulations and conservative treatment. |

| |To make practical training of junior doctors and nurses in A&E. |

| |To make poster on A&E wall with distal radius geometrical anatomical and allowance angles. |

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