Diagnosis of facial fractures

Ann R Coll Surg Engl 2004; 86: 325–328 doi 10.1308/147870804443

Letters and comments Contributors to this section are asked to make their comments brief and to the point. Letters should comply with the Notice printed on the inside back cover. Tables and figures should only be included if absolutely essential and no more than five references should be given. The Editor reserves the right to shorten letters and to subedit contributions to ensure clarity.

Response to paper by Sandhu & Johnson Integrating refugee doctors into the NHS Ann R Coll Surg Engl (Suppl) 2002; 84: 348–9.

consultants have attempted to target their specific needs. We hope that this pilot project will be popular. Correspondence to: Tahir Hussain, Department of Vascular Surgery, Northwick Park Hospital, London, UK. E-mail [email protected]

Tahir Hussain1, Sue Arnold2 1

Consultant Vascular Surgeon, NW London Hospitals NHS Trust, London, UK 2 Assistant Director Access and Development, NW London Workforce Development Confederation, London, UK

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ur own division of general surgery at Northwick Park Hospital has just started a new and novel project integrating three refugee doctors into the department at SHO grade. Media myths prevail that refugees are a burden to our society; yet Home Office research shows that they contribute significantly to the economy by paying more tax than they take out. The British Medical Association database suggests that there are almost 800 registered refugee doctors with more than 60% based in and around London. It is apparent that they are an untapped resource to reduce the present workforce shortages in the NHS. Furthermore, this shortage is likely to increase with the European Working Directive of a 48-h week for doctors to be implemented in the near future. With a grant from the North West London Workforce Development Confederation and the London Postgraduate Deanery, the Trust has employed three refugee doctors who were eligible for registration with the General Medical Council but found difficulty competing in the internal job market in London. All expressed a desire to pursue a career in surgery. We have set a mentoring scheme, as their needs are different and specific. The doctors have taken additional courses such as in colloquial English. Our experience has been that they need help in their communication and interpersonal skills but are well trained in surgical techniques. As the article has suggested, we believe that these doctors are an asset and much needed resource. The addition in manpower has been universally popular and the

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Closure of umbilical port in laparoscopic surgery Sudip Sairikejr Clinical Research Fellow in Surgical Skill & Technology, Academic Surgical Unit, 10th Floor QEQM Building, St Mary’s Hospital, London W2 1NY, UK

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was interested in reading the two technical articles1,2 and the letter3 in recent issues of the Annals. These techniques have been described in the standard way most British surgeons insert their ports and position their patients in laparoscopic cholecystectomy. Laparoscopic cholecystectomy done in the ‘French’ way and laparoscopic anti-reflux surgery have their patients in the Lloyd-Davies position, and have 10 mm ports inserted at the umbilicus and laterally. A safe way to close the umbilical port in these occasions is a combination of Darzi’s technique3 and a modification of Lord’s technique2 in that the laparoscope is inserted into the lateral port and directed towards the umbilicus and simultaneously the shaft of the laparoscope is raised against the anterior abdominal wall, i.e. creating a space between the anterior abdominal wall and the underlying viscera. No pneumoperitoneum is required. This is a quick and safe method of closure.

References 1. Caruana MF, Singh SM. A simple, safe and effective method for laparoscopic port closure. Ann R Coll Surg Engl 2002; 84: 280. 2. Khanduja V, Douek M, Lord MG. Umbilical port closure under direct vision. Ann R Coll Surg Engl 2002; 84: 281 3. Haq AI, Hajii A, Lovett B, Riberio BF, Khan F, Darzi A. Letter. Ann R Coll Surg Engl 2002; 84: 434.

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LETTERS AND COMMENTS

Response to technical tip from F Middleton & J Davis

2. Sidebottom AJ, Lord TC. Single view radiographic screening of midfacial trauma. Int J Oral Maxillofac Surg 1998; 27: 356–7. 3. Raby N, Moore D. Radiography of facial trauma, the lateral view is not required. Clin Radiol 1998; 53; 218–20.

Tissue protector for tibial intramedullary nailing

Response by the author

Ann R Coll Surg Engl 2002; 84: 434

Khursheed F Moos

HV Nagesh

Department of Oral and Maxillofacial Surgery, University of Glasgow Dental School, 378 Sauchiehall Street, Glasgow G2 3JZ, UK

Department of Trauma and Orthopaedics, William Harvey Hospital, Ashford, Kent TN2 40LZ, UK

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agree that using 10-ml plastic syringe as soft tissue protector has all the advantages mentioned in the note. It is important to make sure that reamer is in the medullary canal and not started prematurely in the syringe. This carries the risk of taking plastic bits into the canal, especially with larger reamers.

Response to technical tutorial from KF Moos Diagnosis of facial fractures Ann R Coll Surg Engl 2002; 84, 429–31 Andrew Sidebottom Maxillofacial Unit, Queen’s Medical Centre, Nottingham NG7 2UH, UK

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r Moos provides an excellent overview of the assessment of facial fractures for the CSiG candidate. I would take issue with one minor point. In these days when we are supposed to be using ALARA (as low as reasonably achievable) principles for radiological investigation, I find it difficult that colleagues still stick to the ‘traditional’ teaching that 3 views are necessary for ‘screening’ for midfacial injuries. We, and others, have clearly shown in a completed audit loop1–3 that one OM15 is sufficient in most cases to exclude facial fracture in A&E. Only rarely (8 of 601 cases) were further views required to exclude a fracture. I would add that there is also no necessity to radiograph children under 8 years of age unless there has been a sufficiently violent force. In which case, CT scan is the first line investigation, as there is likely to be a significant injury not simply assessed from plain films (presented but unpublished data).

References 1. Sidebottom AJ, Cornelius P, Allen PE, Cobby M, Rogers SN. Routine post-traumatic radiographic screening of midfacial injuries; is one view sufficient? Injury 1996; 27: 311–3.

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was certainly aware of the papers written by Mr Sidebottom, apart from that in Clinical Radiology. In the best circumstances, a 15° occipitomental view, which is what he recommended, will pick up a fracture of the malar complex. This always assumes that one has a good quality radiograph, but in many cases this is not so. In a major maxillofacial unit, generally speaking, the quality of radiographs is excellent and one does not have a problem with diagnosis from a single film. However, in many peripheral units, particularly small ones, the single view is unsatisfactory: it is often taken under difficult circumstances, and the casualty officer may well not pick up a fracture. At present, I have a medicolegal case which is exactly that: two poor quality films were seen in the accident and emergency department, no fracture was diagnosed. As there was no system for reporting the radiographs, a displaced fracture, which was obvious to an oral maxillofacial surgeon, was missed. With the increasing amount of litigation in relation to missed fractures, I was reluctant in a short paper to bring this out; although I accept Mr Sidebottom’s figures were only 1.3% missed fractures, this was in an optimal situation in a district general hospital with a strong maxillofacial department. There are some advantages in having additional views as they can indicate the type of displacement, which may be helpful in the management of the case. Since the Annals are widely read by surgeons all over the world, I was reluctant to simply suggest the single view. The situation with regard to midface injuries in general is arguable. Where there is first-class radiological reporting of fractures then, again, a single view may be satisfactory. Where this is not the case, additional views can be helpful. There are some disadvantages in not taking a lateral view of the facial bones: where there has been a minimal head injury and severe middle third fractures on several occasions I have seen extensive frontal aerocoeles, which would not have been picked up on an occipitomental view. I accept that in well-organised departments such as Chester, Frenchay and Walton Hospitals, where Mr Sidebottom has worked, there are no problems, but many other small accident and emergency departments which unfortunately Ann R Coll Surg Engl 2004; 86

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are still prevalent in the UK and even more extensively overseas, this suggested situation does not pertain. I do therefore subscribe to Mr Sidebottom’s views in relation to units such as he and I have worked in, but with increasing medicolegal pressure and inadequate radiological services, as well as inexperienced accident and emergency department staff, it is debatable when those changes should be made. Again, Mr Sidebottom’s comments regarding CT scanning for children under 8 years of age – yes, I would agree that this is probably the best way forward, but since CT scanning is not freely available in all parts of the world or even in this country, when children have sustained severe injuries it may still be worthwhile using plain films. In a very short tutorial as was given it is not possible to discuss the pros and cons of different approaches and there is sometimes a need to consider the overall management of the case, apart from a mere diagnosis, as clues to management can often be obtained from additional films – provided a diagnosis has been made. Certainly, a large number of unnecessary films are taken and one would wish to reduce the radiation levels and the cost to the health service, and we should encourage this.

useful contribution in that direction. We are keen, however, to hear the views of the authors on why waiting times varied dramatically between the trial groups and the control group given that average consultation times were nearly comparable. Furthermore, 61.6% of the fracture clinic group comprised of less than 16-year-olds as compared to 41.3% in the trial clinic (nurse) group and 36.0% in the trial clinic (doctor) group. Could the disproportionate number of less than 16-year-olds in the various groups have biased the study in favour of the trial groups? We submit that, on the whole, paediatric cases require more interaction with the parents and need astute management by an experienced clinician.

Reference 1. Shoham-Yakubovich I, Carmel S, Zwanger L, Zaltcman T. Autonomy, job satisfaction and professional self-image among nurses in the context of a physicians’ strike. Soc Sci Med 1989; 28: 1315–20.

Response on behalf of the authors by Stephen C Williams

Response to paper by SC Williams et al. Improving the quality of patient care: patient satisfaction with a nurse-led clinic service Ann R Coll Surg Engl 2003; 85: 115–6 Aprajit Bhalia, Rajiv Bajekal Barnet Hospital, London, UK

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e applaud the authors for introducing nurse-led clinics into the domain of orthopaedic practice. Their effort sets out a compelling argument for nurseled clinics in orthopaedics, a practice largely accepted in other surgical specialties. We are aware that debate rages on this subject. Proponents say this will allow consultants to focus on the more challenging cases in a busy fracture clinic. Furthermore, it will encourage experienced orthopaedic nursing staff to tap their as yet unexplored skills and knowledge base.1 Critics are concerned that nurse-led clinics are just ‘spin’. The clinics disguise the true workload of the consultant who has to carry the can in the unfortunate event of a clinical misadventure. The only way the issue will be resolved is by objectively examining the pros and cons of the case. This study makes a Ann R Coll Surg Engl 2004; 86

7 Beech Road, Oadby, Leicester LE2 5QL, UK

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here has been much interest in the development of nurse-led clinics since the publication of our paper. We have received many visits and welcome more. We continue to run an audit of the service offered. There is no doubt that the service has reduced the load in each fracture clinic. Even if nothing else had been achieved, it is clear to all that the waiting rooms are less full, and patients with straightforward fractures are not made to wait in the same environment as those with more complex injuries. It is true that the workload has changed somewhat; however, this is not perceived to be a problem by the medical staff. We can honestly say that there have not been any clinical misadventures as a result of the service. Where a problem occurs in the clinic, which is rare, the experienced nurses concerned consult the registrar on call. In reality this is an infrequent occurrence. With respect to waiting times, there were no differences between the doctor and nurse groups in the trial. Differences occurred between the trial and the comparative audit probably because of the case mix in the waiting room of the busy fracture clinic,. We think it unlikely that the paediatric caseload influenced the results as the carer completed the questionnaire. In conclusion, patients are satisfied with a nurse-led service, nurses find it gratifying, and our department has benefited from their introduction, we would not wish to turn back. 327

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Response to paper by CP Charalambous et al. Factors delaying surgical treatment of hip fractures in elderly patients Ann R Coll Surg Engl 2003; 85: 117–9 F Dinah Department of Trauma and Orthopaedics, Frimley Park Hospital, Camberley, Surrey, UK

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read this article with interest as I conducted a similar audit in a previous hospital. My retrospective sample consisted of 59 patients (over a 3-month period), ranging from 65 to 95 years (mean, 80.6 years) of age. I would like to draw attention to a few points, as well as mention some of my findings and suggestions. Patient sample The authors included patients from the age of 54 years. This may skew the figures, as in such young patients, an intracapsular lip fracture is more of an orthopaedic emergency than, for example, an extracapsular, fracture in an 80-year-old patient. A further source of bias is the possible discrepancy between the data collected retrospectively and prospectively. Time to operation The authors found that 44.2% of the patients were operated on within 24 h of attending A&E, which compares favourably with 40.7% in my audit. However, they have not mentioned the average waiting time for their sample of 163 patients: in my sample, this was a median of 1.6 days (range, 0.1–15.4 days). I feel that this statistic is useful because, as pointed out by the authors, it allows comparison of hip fracture management between trauma units. For a transAtlantic comparison, a prospective study from New York City (554 patients) found that only 30.0% were operated on within 24 h of arrival with a median time to operation of 1.7 days (range, 1.0–24.3 days).3 Causes of delay The authors found that medical optimisation caused about three-quarters of delays over 24 h, with the rest being due to lack of theatre access. We operated a similar half-day trauma list 6 days a week, but in my retrospective sample, the relative importance of these two causes was reversed, with about two-thirds of delays being due to

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lack of theatre time. Interestingly, another prospective study from Manchester (142 patients) also found that about two-thirds of the delays were due to lack of theatre space.4 Thus, the conclusion from Charalambous and colleagues that ‘medical problems account for most delays’ needs further substantiation. [For the sake of completeness, the New York study3 found that about half of the delays were due to ‘routine medical clearance’ and about a third were due to ‘unavailability of operating suite or surgeon’.] References 1. Audit Commission. United they stand: co-ordinating care for elderly patients with hip fractures. London: HMSO, 1995. 2. Rajmiohan B. Audit of the effect of a fast-tracking protocol on transfer time from A&E to ward for patients with hip fractures. Injury 2000; 31: 585–9. 3. Orosz GM, Hannan EL, Magaziner J, Koval K, Gilbert M, Aufses A et al. Hip fracture in the older patient: reasons for delay in hospitalization and timing of surgical repair. J Am Geriatr Soc 2002; 50: 1336–40. 4. Peterman A, Tadvi J, Calthorpe D. Does early surgery improve the outcome of hip fracture surgery? A prospective study. J Bone Joint Surg Br 2003; 85 (Suppl 1): 37. Correspondence to: Mr F Dinah, SpR in Trauma & Orthopaedics, Frimley Park Hospital, Camberley, Surrey GU16 7UJ, UK. E-mail: [email protected]

Response on behalf of the authors by CP Charalambous University Department of Trauma and Orthopaedics, Manchester Royal Infirmary, Manchester, UK

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e read with interest the comments of Mr Dinah to which we answer the following. We acknowledge that more effort may be put into operating early for hip fractures in young as compared to elderly patients. The median timing of operating in our study was 2 days. As expected, the proportion of patients delayed due to lack of theatre availability will vary from hospital to hospital. Just because two hospitals have the same number of trauma lists, it does not mean that the proportion of delays due to theatre availability have to be equal. This will depend not only on the number of available theatre sessions, but also on the efficiency with which such sessions are used, and more importantly on the volume of trauma work faced by the hospital. Thus, we feel that direct comparison of Manchester Royal Infirmary with Mr Dinah’s hospital is not feasible.

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