Journal of Trauma & Orthopaedics - Vol 8 / Iss 2 by British Orthopaedic Association

Journal of Trauma and Orthopaedics Volume 08 | Issue 02 | June 2020 | The Journal of the British Orthopaedic Association | boa.ac.uk

Training in orthopaedics: Non-accidental injury in COVID-19: My experience The show must go on p12 children during COVID-19 p14 of testing positive p16

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Journal of Trauma and Orthopaedics

Contents

In this issue...

3 5

From the Executive Editor

Bob Handley

From the President: Working together – the way forward

6- 10 Latest News 12 Training in orthopaedics:

The show must go on

Morgan Bailey, Sabina Barbur, Daniel Cadoux-Hudson, Rishi Das and Daniel Marsland

14 Non-accidental injury in children in

the time of COVID-19 pandemic

Emily Baird

My experience of testing positive

16 Coronavirus (COVID-19):

Kathryn S S Dayananda

18 An orthopaedic surgeon’s diary at

the Nightingale Critical Care Unit

Niall Eames

22 Orthopaedic care changes since the

Don McBride

B.C. (Before COVID-19) time period

Mary Campbell, Andrew Hughes, Brendan Daly, Aedín Hanahoe, Darren Moloney, Iain Feeley, Eoin Sheehan and Khalid Merghani

26 Commentary on

the Swansea Hip interrogation Fracture Tool (SHiFT)

Michael Cronin, Mark Mullins, Praveen Pathmanaban, Paul Williams and Matthew Dodd

28 COVID-19 causes a SHiFT in

the sands for proximal femoral fracture management?

Michael Cronin, Mark Mullins, Praveen Pathmanaban, Paul Williams and Matthew Dodd

causes a SHiFT in the sands for proximal femoral fracture management? A plea for caution

32 A letter in response to: COVID-19

Peter M Lewis, Miriam Day, Lisa A Williams, Laura Lougher, Glenn J Clewer and Stephen Sarasin

34 A response to the letter by Lewis et al.

from the authors of: COVID-19 causes a SHiFT in the sands for proximal femoral fracture management?

Michael Cronin, Mark Mullins, Praveen Pathmanaban, Paul Williams and Matthew Dodd

John Seddon Hopkins, Anthony John Hall

37 In Memoriam:

Download the App The Journal of Trauma and Orthopaedics (JTO) is the official publication of the British Orthopaedic Association (BOA). It is the only publication that reaches T&O surgeons throughout the UK and every BOA member worldwide. The journal is also now available to everyone around the world via the JTO App. Read the latest issue and past issues on the go, with an advanced search function to enable easy access to all content. Available at the Apple App Store and GooglePlay – search for JTO @ BOA.

We are committed to sustainable forest management and this publication is printed by Buxton Press who are certified to ISO14001:2015 Standards (Environmental Management System). Buxton prints only with 100% vegetable based inks and uses alcohol free printing solutions, eliminating volatile organic compounds as well as ozone damaging emissions. JTO | Volume 08 | Issue 02 | June 2020 | boa.ac.uk | 01

69%

reduction of deep infections in hip hemiarthroplasty after * fractured neck of femur

Bone cement with gentamicin and clindamycin * Sprowson AP et al. Bone Joint J 2016; 98-B: 1534â&#x20AC;&#x201C;1541

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Credits JTO Editorial Team l l l l

Bob Handley (Executive Editor) Rhidian Morgan-Jones (Editor) David Warwick (Medico-Legal Editor) Tricia Campbell (Trainee Section Editor)

BOA Executive l Don McBride (President) l Phil Turner (Immediate Past President) l Bob Handley (Vice President) l John Skinner (Vice President Elect) (Honorary Treasurer) l Simon Hodkinson (Honorary Secretary) l Deborah Eastwood

BOA Staff Executive Office Chief Operating Officer

- Justine Clarke

Personal Assistant to the Executive

- Celia Jones

Education Advisor

- Lisa Hadfield-Law

Policy and Programmes Director of Policy and Programmes

- Julia Trusler

Programmes and Committees Officer

- Harriet Wollaston

Educational Programmes Assistant

- Eliza Khalid

Communications and Operations Director of Communications and Operations

- Emma Storey

BOA Elected Trustees l Don McBride (President) l Phil Turner (Immediate Past President) l Bob Handley (Vice President) l John Skinner (Vice President Elect) (Honorary Treasurer) l Simon Hodkinson (Honorary Secretary) l Deborah Eastwood

Interim Director of Communications and Marketing

- Annette Heninger

Marketing and Communications Officer

- Sabrina Nicholson

Membership and Governance Officer

- Natasha Wainwright

Education and Online Exam Project Manager

- May Elphinstone

Publications and Web Officer

- Nick Dunwell

l Colin Esler

Finance

l Peter Giannoudis

Director of Finance - Liz Fry

l Grey Giddins l Robert Gregory l Anthony Hui l Andrew Manktelow

Deputy Finance Manager - Megan Gray Finance Assistant - Hayley Oliver

l Ian McNab

Events and Specialist Societies

l Fergal Monsell

Head of Events - Charlie Silva

l Rhidian Morgan-Jones

Events Administrator - Venease Morgan

l Hamish Simpson l Arthur Stephen l Duncan Tennent

Exhibitions and Sponsorship Coordinator

- Emily Farman

UKSSB Executive Assistant - Henry Dodds

Advertising

All advertisements are subject to approval by the BOA Executive Board. If you’d like to advertise in future issues of the JTO, please contact the following for more information: Open Box M&C, Regent Court, 68 Caroline Street, Birmingham B3 1UG Email: inside@ob-mc.co.uk | Telephone: +44 (0)121 200 7820

Disclaimer

The articles and advertisements in this publication are the responsibility of the contributor or advertiser concerned. The publishers and editor and their respective employees, officers and agents accept no liability whatsoever for the consequences of any inaccurate or misleading data, opinions or statement or of any action taken as a result of any article in this publication.

BOA contact details

The British Orthopaedic Association, 35-43 Lincoln’s Inn Fields, London WC2A 3PE Telephone: 020 7405 6507

From the Executive Editor Bob Handley

trange and strained times. Writing an editorial that will be read a few weeks later is always risky business but even more so when surrounded by such volatility. It is, however, the essence of so much of what we do; we make the best judgement we can in the circumstances that prevail and proceed. Whether those circumstances be a tricky problem in theatre or the fallout from a pandemic we carry on. This special edition of the JTO charts some of our efforts. The normal printed JTO had been cancelled but then an opportunity arose to partially resurrect it as special on-line PDF version. To keep up with the ever changing world of COVID-19 we had already started publishing articles in a rapid turn-around Journal called the TJTO&C or the Transient Journal of Trauma Orthopaedics and the Coronavirus. This PDF version of JTO is in the main a compilation of those articles, with some updates and commentaries. The swing in the pervading mood over the last eight weeks has been extraordinary; an acute fear of being overwhelmed by pandemic respiratory failure morphing into a pervasive threat of endemic Coronavirus. The articles we have chosen reflect this mood swing. Some document the redeployment and experiences of individuals in the acute phase. ‘An orthopaedic surgeon’s diary at the Nightingale Critical Care Unit’ page 18 will be read in the future in a way similar to how I heard my parents describe the Blitz. A personal story of ‘Coronavirus (COVID-19): My experience of testing positive’ page 16 will hopefully soon seem like a relic of a bygone age. They are a record of what happened, a Pepys diary of 2020. There are more philosophical issues that arose. The article that promoted the most debate was that detailing SHiFT, a potential response to the anticipated collapse in resources which threatened. What would be the consequences of this on managing our normal urgencies, the exemplar for T&O being the hip fracture. It confronts triage of a condition with a risk of mortality, which for most of us has only ever been role play. We did it on our ATLS course but there was now the prospect of it happening for real. The Armageddon that was feared did not materialise but chronicling the planning exercise is of value. The acute loss of resource may now be replaced by a chronic one. With a morass of unpredictability awaiting; slower operating, fewer beds, PPE, staff testing, patient testing, consent, residual fear, the list could go on. This continues to generate noise in the unending health dilemma of whether we need central diktat or local solutions; one with its inflexibility the other risking a postcode lottery. A full retrospective can be had in a future bumper edition of JTO or a component of a Congress, but we have no idea when. Until then the TJTO&C will provide a forum. It is now customary to sign off with the invitation or encouragement to keep safe, the inference often being to hunker down to stay alive. I like the adage that “Life is movement and movement is life.” I don’t think that this was intended to apply only to the muscles used in breathing. In T&O our most common objective is restoration of function, this should now be the objective for both society and the individual. Phase one of COVID-19 could be summed up as “Be safe, don’t do anything” now we need “Do something but safely!” Those could just be hollow words but what better example could we have of the benefits of restoring function than Sir Tom. The raw statistics don’t look that good for a man in his late 90s with a hip fracture, but a broad smile and £33 million for the NHS is quite a result. We salute you Sir! n Cover image courtesy of Mike Dawson: Painting of Captain Sir Tom Moore.

Credits

Story of the front cover ever fundraiser. The painting by Elstreebased artist Mike Dawson was donated to Watford General Hospital.

ur cover image for this issue of JTO is a painting of Captain Sir Thomas Moore, who has captured the hearts of the nation during the COVID-19 pandemic and become Britain’s greatest-

Former British soldier Captain Tom, who reached the milestone of his 100th birthday on Thursday 30 April, took on the challenge of walking 100 laps of his 25-metre garden in Bedfordshire. His initial aim was to raise £1,000 for NHS Charities Together as a ‘thank you’ to the staff who had helped him recover from cancer and a broken hip. When his walk generated media interest, hundreds of thousands of people from all over the world began to contribute to his fund. By the time his fundraising campaign had closed he had raised in excess of £33 million! In recognition of Captain Tom’s extraordinary fundraising efforts, his hundredth birthday was marked in a

number of ways, including flypasts by the Royal Air Force and the British Army. He received over 150,000 cards, and was appointed as honorary colonel of the Army Foundation College and his knighthood was announced on 19 May. Mike Dawson, who specialises in ‘pop art’, painted Captain Tom wearing his blazer and medals, backed by the NHS rainbow. Mike said: “Like everyone else, I’ve been fascinated by Captain Tom’s story and I’ve been hugely impressed by his pluck, his humility and his charm. He’s been a breath of fresh air and he’s lifted the nation’s spirits. It’s an honour to paint him and I’m delighted that the wonderful staff at Watford General Hospital are happy to receive the end result.” Images and videos of Mike’s paintings can be seen on Facebook.com/MikeDawsonArt or mike.dawson.art.

Leave a lasting legacy Whether you’re someone who is suffering from a musculoskeletal disorder or whether your life’s work is helping those who are suffering; you can really make a difference. Once you have considered your immediate friends and family; please consider leaving a life-changing gift to Joint Action to fund ground-breaking orthopaedic research. Your donations support the BOA Orthopaedic Surgery Research Centre (BOSRC), based at York Trials Unit, which works with the BOA in expanding the number of trials in the UK related to Trauma and Orthopaedics. Your generous donations are helping us to advance Trauma and Orthopaedic research. Thank you very much! Remembering a charity in your Will is simple. For an easy step-by-step guide to everything you need to know about leaving a legacy to Joint Action, please visit https://www.boa.ac.uk/research/joint-actionthe-orthopaedic-research-appeal.html.

From the President

Working together – the way forward Don McBride

As we left Australia and New Zealand in October 2019 I said to my better half – “this is only the start of an exciting year ahead”. Little did I know how right I was but clearly not in the way I expected. The latter part of 2019 and early 2020 were completed in a fairly straightforward manner and even a few murmurings about Wuhan in China from December onwards did not initially, at least, register that a potentially catastrophic global event was about to ensue.

hen writing my last JTO Presidential article for the March edition, plans were coming along very nicely for the Annual Congress in Birmingham and the visits to the American Academy of Orthopaedic Surgeons, Canadian Orthopaedic Association, American Orthopaedic Association and South African Orthopaedic Association meetings were all organised. The February Council and Executive meetings had been completed fairly uneventfully and then ‘all hell let loose’. COVID-19 arrived in Europe catastrophically affecting Italy and Spain then sweeping towards the UK. Lockdown ensued with variable political responses across the globe. Gradually, all meetings were initially postponed but then cancelled including, unfortunately, our own in its normal form. However, a number of societies have organised alternatives including webinars, instructional lectures and educational events. We are currently looking at these alternatives both before and at the time of the proposed Congress in September. Keep those dates free and watch out for updates. My theme for this year’s Congress was ’Working Together – the Way Forward’. In the wake of the pandemic I do not believe that you could find a better term for the incredible response of the Trauma and Orthopaedic community in the UK. From the very outset the BOA have provided regularly updated information online on a wide range of topics with support and input from many specialist societies and individuals across the membership. (This work has been very well received by our members and links to the various resources can be found on page 08). The BOA has worked with NHS England, the Royal Colleges, Public Health England and other groups including GIRFT contributing to and assisting with their own updates, for example, on PPE. However, what has been most evident is our members’ fantastic efforts, resilience and ability to adapt to the necessary changes in our working environment to ultimately protect the welfare of our patients. This shall, I am sure, be maintained throughout the pandemic and when it ends whenever exactly that might be. I should like to finish by thanking the BOA staff who have responded magnificently to the difficulties, which have occurred during this time. Their hard work and flexibility have been exemplary. n JTO | Volume 08 | Issue 02 | June 2020 | boa.ac.uk | 05

Latest News

The BOA’s response to COVID-19 The BOA has been very busy producing guidance documents and articles throughout the COVID-19 pandemic, working with the Colleges and NHS bodies to ensure patients and surgeons are supported during these unprecedented times. We highlight some of the recent work we have been doing here. We are very grateful to those who have committed time to helping the BOA with this output when many are working under very difficult circumstances.

Guidance for restarting non-urgent care As part of the move into the second phase of the COVID-19 pandemic, the topic of restarting nonurgent care is high on priority lists around the UK. The BOA has published its own guidance to help with the shift in practice that will be seen as we enter this new stage of response to COVID-19, and the restarting of elective orthopaedic care. The guidance we have created includes two documents: one is a summary document, which contains core principles about restarting aspects of orthopaedic care, whilst the second is a more detailed guidance document which provides further in depth discussion of the key points. We are aware that this shift towards restarting care will have many changes and so we will be updating these documents regularly as more information becomes available in this evolving situation. The documents can be viewed at: www.boa.ac.uk/guidance and we welcome any feedback to us at: policy@boa.ac.uk.

BOA Webinar - The Next Phase: Recovery of T&O Surgery Following the publication of our guidance, the BOA hosted a webinar to address some key points with regard to restarting of elective and non-urgent care within T&O. The panellists gave insights into their own experiences, including a presentation on the paediatric implications from Prof Deborah Eastwood as well as the anaesthetic view from Prof William Harrop-Griffiths of the Royal College of Anaesthetists. Following the presentations, time was given for discussion and questions from the audience, and the BOA would like to thank the audience for their engaging questions during the second half of the session. We had a large turnout and very positive response to the webinar and expect this to be the first of many. In case you missed it you can view the webinar at: https://www.boa.ac.uk/latest-news/ changes-to-orthopaedic-services-during-covid-19.html.

MDR regulations

The European Commission has adopted a proposal to postpone the application of the Medical Devices Regulation by one year. This decision has taken into account the unprecedented challenges of the coronavirus pandemic and the need for an increased availability of vitally important medical devices across the EU. The BOA will keep members updated with any further information we receive. More information and the full statement can be found at https:// ec.europa.eu/commission/presscorner/ detail/en/ip_20_589.

Cumberlege Report delayed The Independent Medicines & Medical Devices Safety Review was due to publish its report on surgical mesh implants on 24th March, however due to the Coronavirus pandemic the Review has decided to postpone this planned publication. The BOA will continue to keep abreast of any developments and will inform members when the report is published.

NICE Joint replacement update The BOA was expecting the publication of the NICE Joint replacement (primary): hip, knee and shoulder guideline in late March, following a consultation which we responded to. However, due to the COVID-19 pandemic, NICE have confirmed they will not be publishing any draft or final guidelines until further notice. We will endeavour to keep members informed with any updates on this.

BOA Training Orthopaedic Trainers (TOTs) and Training Orthopaedic Education Supervisors (TOES) courses Delivery of future BOA-run face-to-face TOTs and TOES courses is being reviewed in keeping with the lockdown restriction guidelines. It is expected that face-to-face delivery of these courses will resume on the dates listed below. Further information will be updated on the BOA website at: https://www.boa.ac.uk/courses when course bookings are open. - TOTs: 3rd – 4th September 2020 (BOA London) - TOTs: 10th – 11th December 2020 (BOA London) - TOES: 18th December 2020 (BOA London)

Latest News

NHS Change Challenge The BOA is very proud to be supporting NHS England with their ‘NHS Change Challenge’. COVID-19 has changed healthcare delivery in the UK and there are many examples of new, innovative ways of working that have been rapidly developed across the NHS. This initiative aims to capture all of these beneficial changes across T&O and MSK services, and lock them into the new ways of working in the NHS going forward. Two of our committee members – Nick Aresti (Orthopaedic Committee) and Alex Trompeter (Trauma Committee) – have been working as the Champions for their respective areas on this project, and we are very excited to see all of the ideas and responses that are submitted. To find out more or get involved, visit their website https://nhschangechallenge.crowdicity.com.

Virtual Training Orthopaedic Trainers (V-TOTs) With the suspension of face-toface educational courses, the BOA have developed a Virtual Training Orthopaedic Trainers (V-TOTs) course facilitated by the BOA Educational Advisor Lisa Hadfield-Law. The V-TOTs course is currently being delivered primarily for those concerned about meeting imminent CCT requirements, but anyone who wishes to register their interest should email policy@boa.ac.uk to be added to a waiting list. Details about the structure, assessment and cost of the V-TOTs course can be found on our website: https://www.boa.ac.uk/VTOTS.

Apply Now: Associate Surgical Specialty Lead (SSL) posts Late in 2019, a new team of SSLs were appointed by the BOA and the Royal College of Surgeons of England, to help support research in surgery throughout the UK. Since the launch of this initiative, one of the overriding objectives has been to develop trainee involvement in surgical clinical research. Three Associate SSL posts have now been created to give trainees an opportunity to work with the SSLs and shape the course of research in their speciality. To find out more about these posts, including how to apply, please see the BOA website: https://www.boa.ac.uk/research/surgical-specialty-leads-for-clinical-trials/ associate-ssl-recruitment.html.

UK and Ireland In-Training Examination (UKITE) The dates for the UKITE 2020 have now been confirmed as 4th – 11th December 2020. The UKITE is an online annual assessment that allows trainees of all grades to practice for Part 1 of the FRCS (Tr and Orth) examination, with similar formatted questions based on the UK and Ireland T&O Curriculum. Information on UKITE is available on the BOA website: www.boa.ac.uk/ukite. The BOA is also seeking Editors to contribute to the authoring process of questions for the UKITE. For more information email ukite@boa.ac.uk. JTO | Volume 08 | Issue 02 | June 2020 | boa.ac.uk | 07

Latest News

BOA Educational Support during COVID-19: A message from Lisa Hadfield-Law, BOA Educational Advisor Trainees are worried about long awaited rotations, exams, fellowships etc. and face anxiety at home and at work. Our SAC continues to work on ways to minimise the impact of COVID-19 on training and to reduce worry load. To support this work, the BOA has produced a screencast suggesting ways of squeezing the learning juice out of our unusual and unexpected clinical experiences. View the screencast at: https:// www.boa.ac.uk/latest-news/trainee-and-tpdissues.html. Many of you will be using this time to prepare your portfolios to reflect requirements of the new curriculum. We have reviewed the GPC framework published by the GMC which sets out essential Generic Professional Capabilities (GPCs) integrated into our new curriculum. We have suggested specific capabilities which may be relevant to work during the pandemic and might provide an opportunity to develop in these areas. Download the document at: https://www. boa.ac.uk/resources/generic-professionalcapabilities-gpcs-which-may-be-relevant-towork-during-covid-19-pandemic.html. Those who have been working alongside others from different specialties or professions can access invaluable feedback

discussions. It shouldn’t take long to record these and we have suggested quick ways to do this on ISCP at: https://www.boa.ac.uk/ resources/how-to-register-assessors-whodo-not-have-iscp-accounts.html. Regional teaching shifted to a virtual medium remarkably quickly. The BOA has been able to support regions with ideas to make sessions work. Amazing progress has been made by many: terrifically interactive events even breaking into small groups.

Other COVID-19 documents and resources available on the BOA website

In response to concerns about requirements for CCT, the BOA evolved their Training Orthopaedic Trainers into an entirely virtual programme. They turned this around in seven days with the first cohort of nine starting on the 24th April. One participant has already said “Really getting a lot of useful insight, genuinely wish I’d done this a lot sooner as a learner.” We are now turning our attention to virtual preparation for the new curriculum and the Training Orthopaedic Educational Supervisors programme. n

• BOAST: Management of patients with urgent orthopaedic conditions and trauma during the coronavirus pandemic – The BOA Trauma Committee, alongside several Specialist Societies, worked to produce this BOAST that was recently updated to include non-urgent paediatric guidance. Download the BOAST at: https://www.boa.ac.uk/resources/covid-19-boasts-combined.html. • Information for BOA members on the website – The BOA has compiled links to a large number of resources across the NHS, PHE, Specialist Societies, the GMC as well as many other sources. The information covers a wide range of topics including general professional issues, trainee and TPD issues and infection control and prevention relevant to T&O. View the various resources at: https://www.boa. ac.uk/resources/information-for-boa-members-on-trauma-and-orthopaedic-care-inthe-uk-during-coronavirus-pandemic.html. • TJTO&C – The JTO editorial team has created the Transient JTO and the Coronavirus as a place to host discussion and articles during this pandemic. Read the articles at: www.boa.ac.uk/tjto&c. • Guidance for casting practice – The BOA Casting Committee created some guidelines to help with casting practice during the COVID-19 pandemic, due to a need for reducing hospital attendances and enabling home management where possible. Download the guidelines at: https://www.boa.ac.uk/resources/guidancefor-casting-practice-in-the-current-covid-19-pandemic.html. • Patient FAQs – At the start of the pandemic, we created some patient FAQs to give some support and reassurance to those patients who may be concerned with their surgery being cancelled. Access the FAQ’s at: https://www.boa.ac.uk/ resources/coronavirus-boa-faqs-for-patients.html.

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34th Edinburgh International Trauma Symposium and Instructional Trauma Course 17th to 28th August 2020

In view of the Covid pandemic, the programme this year will be run entirely on-line. The world has changed this year as a result of the Covid-19 pandemic. So, for the first time in its 34 year history, the Symposium will not be held as a physical meeting in Edinburgh in August. Instead, we intend to deliver the same high quality education via our website on a virtual platform. As usual, there will be an Instructional Course aimed at trainees and those requiring an over-view and update in orthopaedic trauma, running in parallel with the Trauma Symposium, aimed at established surgeons interested in recent developments, debates, and controversies. Highlights of these courses include: • An experienced and enthusiastic faculty of national and international experts. • Our programme of Instructional and Symposium talks, available to watch whenever convenient. • Live, interactive, case-based discussion sessions run daily during the fortnight of 17th-28th August • Additional material including cadaveric dissections of surgical approaches and techniques.

Early bird discount available, book before 31st May 2020

Further information and a detailed programme are available on our website: www.trauma.co.uk or by email: symposium@trauma.co.uk. SPONSORED BY The Orthopaedic Trauma Society

www.trauma.co.uk symposium@trauma.co.uk.

Latest News

BOA Annual Congress 2020 D

ue to the impact of the evolving COVID-19 pandemic, the BOA leadership have made the difficult decision to cancel the live 2020 Annual Congress, due to be held 15th - 18th September 2020 in Birmingham. We will still be running some elements of the Congress virtually over the same week in September, with plans currently in development to deliver educational and policy support. We will update members as

plans develop and will keep the website updated with the latest information at www.boa.ac.uk/Congress. BOA President Mr Don McBride said: “Our mission is to Care for Patients and Support Surgeons which now feels more relevant than ever. We were very much looking forward to welcoming our delegates from across the globe to

Birmingham but in these unprecedented times difficult decisions have to be taken. We are extremely grateful for your understanding and patience. Protecting people’s health, patients and clinicians alike, is of upmost importance and should be at the forefront of all our efforts. The Congress will return in Aberdeen in 2021 where we look forward to welcoming you in happier and less turbulent times.” n

About Joint Action The Joint Action appeal by the British Orthopaedic Association (BOA) aims to help patients by raising funds for research to improve orthopaedic treatment with the potential to improve the quality of life of those who suffer from arthritis, bone cancer and other adult or paediatric conditions, or to those who have endured a major trauma. General fundraising has been hit very hard by the COVID-19 pandemic. Thousands of fundraising events have been cancelled and many charities, particularly smaller ones, are struggling to maintain services because of this huge reduction in income. Thank you to everyone who took part in raising money through The 2.6 Challenge and #GivingTuesdayUK, through these campaigns over £10 million has been raised for UK Charities! Save the date for the next #GivingTuesdayUK which is due to take place on Tuesday 1st December. The London Marathon 2020, is now postponed and will now take place on 4th October, please support our London 10 | JTO | Volume 08 | Issue 02 | June 2020 | boa.ac.uk

Marathon runners by donating online at Just Giving (https://justgiving.com/campaign/ JAlondonmarathon2020) or the JA Virgin Money Giving page (https://bit.ly/2TMOg6U). The ASICS London 10K which was due to take place on 5th July will no longer be taking

place on this date, please keep an eye on our website Joint Action page at: www.boa.ac.uk/ joint-action for further updates. The Prudential RideLondon-Surrey 46 and 100, which was due to take place on Sunday 16th August, has now been cancelled. n

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Features

Training in orthopaedics: The show must go on Morgan Bailey, Sabina Barbur, Daniel Cadoux-Hudson, Rishi Das and Daniel Marsland

A Morgan Bailey is an ST7 Registrar on the Wessex rotation, previously the Women in Surgery Representative for BOTA, she is currently the BASK research fellow for 2020.

Sabina Barbur is an ST7 Orthopaedic Registrar on the Wessex Rotation. Her primary interests are trauma and upper limb surgery.

fter a hard winter that saw numerous elective cancellations due to bed pressures in many orthopaedic units, we have been hit with a much bigger crisis in the form of COVID-19. It was immediately obvious that this was going to have a significant impact on the training of orthopaedic registrars both with regards to our day-to-day clinical activities and the extra-curricular events we attend to develop ourselves as surgeons. For some, the impact has been even greater, such as those who have fallen victim to postponement of exams and ST3 National Selection.

â&#x20AC;&#x153;After an initial period of adjustment to the change in clinical activities and the evolving rota patterns, consultants and registrars alike collaborated to help develop an educational program that could be delivered in the context of social distancing and irregular work patterns.â&#x20AC;?

The impact of COVID-19 upon training will be felt not only nationally but across the globe1. Our unit has traditionally had a reputation for delivering regular high quality teaching in addition to the scheduled clinical commitments of theatre lists and clinics. After an initial period of adjustment to the change in clinical activities and the evolving rota patterns, consultants and registrars alike collaborated to help develop an educational program that could be delivered in the context of social distancing and irregular work patterns. We would like to share our ideas and experience to encourage other units to do something similar. We feel this has a two-fold benefit of maintaining orthopaedic focus and raising morale in a time when many of us may feel lost without regular access to power tools.

Journal club Prior to the changes to working patterns that were introduced in the department in response to the COVID-19 pandemic, Trauma and Orthopaedic Journal Clubs were undertaken once a month. In light of the significant disruption, and the need to respect the Governmentâ&#x20AC;&#x2122;s social distancing policy during the pandemic, the journal clubs were postponed.

Following the initial period of upheaval we have reintroduced the regular journal club teaching using video conferencing facilities. The Trust has access to Microsoft TEAMS which is a secure messaging application that also has the facility to run video conferencing and file sharing. This was chosen as the preferred method of delivering these education sessions as it allows for dissemination of material and can keep an ongoing record of meetings and conversations. The journal clubs have been set up fortnightly in the evenings, and have been based on the preexisting timetable in order to allocate supervising consultants equitably. Each consultant allocates papers relevant to their specialty. These papers are a combination of seminal work behind current orthopaedic practices and recent publications to enable consultants and registrars alike to stay up to date with current research outcomes. After the effects of the pandemic have passed, we hope to return to the face-to-face model that existed previously, however, the hope is that the lessons learned from delivering quality teaching remotely can be applied in the future. This will be a useful tool in the world of limited working hours and shift patterns that are commonplace in the modern medical workplace.

Registrar lead FRCS basic sciences tutorials Another regular feature of our departmental activity included a registrar lead lunchtime tutorial. Held once a week and supervised by a magnanimous former FRCS examiner, this was a session not to be missed. Topics were allocated to both pre exam and post exam trainees and the opportunity to present a section of basic sciences to peers has the benefit of deepening understanding in an informal learning environment. The tutorials were well attended, even managing to assemble junior FY1/2s, who were keen to broaden

Features

Dan Cadoux-Hudson is a Trauma and Orthopaedic ST5 Trainee in the Wessex Deanery. He is currently on the Wessex Chief Resident management training programme run by HEE Wessex.

their knowledge and perhaps spark an interest in a career in orthopaedics.

Rishi Das is an ST7 Trauma & Orthopaedic Registrar on the Wessex Rotation.

In times of social distancing and altered working practices, we were all anxious for the tutorials to continue their success. The first two sessions on Zoom covered the scintillating topics of lubrication and wear, and the structure of cartilage. Those who could not attend ‘live’ still had the opportunity to access recordings of the sessions for future enjoyment. This serves a second purpose of being able to develop a bank of revision resources, and when it comes to basic sciences, most of us need all the help we can get!

Consultant delivered tutorials

Daniel Marsland is a Consultant foot and ankle surgeon in Hampshire Hospitals NHS Foundation Trust. He is the local research lead and the education lead for the Wessex Deanery.

Keeping orthopaedic consultant morale high during a crisis could prove difficult after closure of theatre and redeployment of skills. In place of elective operating, the orthopaedic consultants now work shifts in the Emergency Department, delivering a front of house Minor Injuries Unit and also in in Critical Care as part of a ‘proning team’. We therefore needed to engage them in the education process from day one to ensure that we all still felt part of a unit and team. They volunteered to run 60-minute subspecialty tutorials with discussion time each week, which gave them free rein of the subject choice as long as it was pitched at the level of the FRCS. This provided the opportunity to stay in touch with both the registrars who had swapped clinics for ward cover but also fellow consultants within their specialty. The timetable was coordinated by a registrar to prevent overlap of topics. A Microsoft TEAMS group was set up for all registrars and other trainees who wished to be involved to access on a weekly basis at a

set time making it a regular session on our timetables. By keeping it virtual, this allowed all of us to access it whether at work or off site. These sessions have been recorded to create an online database of subspecialty lectures for the department but also will be used to support the Wessex deanery registrar teaching program in the event that reduced group contact continues into the next academic year. We all feel this has created both a learning platform but also a level of camaraderie, communication and teamwork between us.

Conclusion Different orthopaedic departments will find their working patterns and department dynamic suit different types of training. It takes collaboration on the part of both the trainees and the consultant bodies to develop a system that works for their own department. The net result is likely to be an overwhelmingly positive one. At the end of the day, most of us are in this specialty because of our passion for the subject matter, so anything we can do to keep this passion alive must be worthwhile. Whether you are sat home self-isolating, taking on new roles in the Minor Injuries Unit, or rediscovering your cannulation skills because your juniors have all been redeployed to the medical teams, remember we are still orthopaedic surgeons, and the show must go on. n

References 1. Kogan M, Klein SE, Hannon CP, Nolte MT. Orthopaedic Education During the COVID-19 Pandemic. J Am Acad Orthop Surg. 2020 Apr 8. [Epub ahead of print].

Features

Non-accidental injury in children in the time of COVID-19 pandemic Emily Baird

Non-accidental injury (NAI) is often considered to be a silent pandemic. Even in the best of times, sadly, abuse goes unnoticed and children come to harm. At its most extreme, this leads to the death of the child, and worldwide, there are estimated to be 50,000 deaths each year1.

T Emily Baird is a Consultant Paediatric Orthopaedic Surgeon at the Royal Hospital for Sick Children in Edinburgh, with an interest in trauma, and the paediatric hip and foot. Emily has been the President of British Orthopaedic Traineesâ&#x20AC;&#x2122; Association, and now sits on the Education Committee of the British Society for Childrenâ&#x20AC;&#x2122;s Orthopaedic Surgery and is the Head of Education for the South East Scotland T&O ST programme.

here are of course subtleties to NAI, a spectrum encompassing any act, or failure to act, that results in serious physical or emotional harm, sexual abuse, neglect or exploitation of a child. We have come a long way since Caffey2 first described the phenomenon of parental maleficence associated with subdural and retinal haemorrhages, and multiple fractures, in the 1940s. There are whole teams, guidelines, standards and screening tools to safeguard and protect children, which have lowered mortality. However, despite this, the subtle, initial presentations can be missed, and COVID-19 presents the perfect storm for the escalation of NAI. The silent pandemic, becoming even more silent and more deadly in the face a global, viral pandemic.

NAI is more likely to happen Some departments have reported an increasing number of NAI cases3, and when the risk factors for NAI are examined, this comes as no surprise. However, the sad truth is that the abuse will be hidden away, and most departments have in fact seen less referrals to Child Protection recently. Social isolation is a risk factor intrinsic to the perpetrator of abuse and intrinsic to the family structure. As we have all been asked to limit our social contact in the light of COVID-19, the support that normally comes with socialising with friends and wider relatives is lost. The sudden withdrawal of nurseries, schools and youth programmes takes away not only the

respite of childcare, but also the early warning system that these institutions would normally provide. Children with developmental delay and additional needs are at particular risk of abuse, and the loss of respite and support networks for families with children with additional needs is a particularly cruel blow. Social isolation for many families means confinement, often with multiple children, in small dwellings with no access to outdoor spaces in which families can relive the stress of lockdown. These conditions make for a stressful and volatile environment. Domestic abuse has said to have surged amid lockdown, with the number of deaths (including those of children) more than double the average number4. Mental health services are also particularly fragile at this time. Mothers with post-natal depression and psychosis may have less support, and infants are particularly vulnerable in this setting. Any member of the household may have mental health issues, including substance abuse, which may be less well supported in these challenging times, posing a risk to children living with them. NAI is known to be more prevalent in families with lower incomes, and financial uncertainty has been further associated with increasing this risk. This was seen during the last economic recession, where there was a substantial increase in abuse and mortality from non-accidental head trauma5. Through financial uncertainty, COVID-19 adds yet another element of stress to a precarious situation for many children, and this effect will be long lasting.

Features

Risk factors heightened by COVID-19 • • • • • •

Social isolation Lack of early warning system Loss of support systems Lowered income and financial uncertainty Perceived lack of access to healthcare Healthcare systems under stress

NAI may go unnoticed Not only are many families under extremely stressful circumstances, but healthcare systems are too. In some settings the burden of COVID-19 has presented a real challenge to maintain the standards that are normally in place. Staff are working out with their normal roles and may not be as familiar with the presentation of NAI. Although we are taught that a ‘corner fracture’ is pathognomonic of NAI, any fracture can represent abuse and we should be particularly

aware of fractures of differing ages, occult fractures and fractures of long bones in nonambulant children. It is worth bearing in mind that a third of children subjected to physical abuse have fractures6, and if a child less than 18 months old has a fracture, there is a one in eight chance that this was sustained non-accidentally7. A high index of suspicion, whether in the Emergency Department or Fracture Clinic is paramount, and the involvement of the local Child Protection Team is essential.

“In some settings the burden of COVID-19 has presented a real challenge to maintain the standards that are normally in place.”

The additional challenges of treating NAI It is common for NAI to present in a delayed fashion, but we can expect to encounter further

History

Examination

Radiological findings8,9

Delay in presentation

Does the child look well cared for?

Multiple fractures

Inconsistencies in history

Is the child behaving appropriately?

Fractures of differing stages of healing

Lack of overt trauma

Are the carers behaving appropriately?

Children <3 years old

Bruising and burns • Atypical places • Differing ages • Differing shapes

Femoral fractures • Midshaft • Especially if child <18/12 old

Child with additional needs Lack of medical condition which predisposes to bone fragility

Injuries to face, mouth, genitals, perineum, eyes

Humeral fractures • Midshaft • Especially if child <24/12 old Skull fractures Rib fractures Corner fractures Subdural haemorrhage

Table 1: The presentation of NAI

delays in presentation and a potential surge in cases once the lockdown has fully lifted. Once recognised, the child should be admitted to the hospital, even with the current risks and restrictions. It is only in the hospital that the child can be considered in a place of safety. The processes to investigate NAI, such as the discussion between healthcare providers, social work and police may not be as rapidly achievable, and the length of stay may be dictated by this process, rather than the orthopaedic treatment.

Discharge planning for the child will be challenging. Under normal circumstances, the child may be discharged with additional supervision, discharged to the care of another member of the family, or into an emergency foster placement, all with increased social work support. All of these options are currently compromised by COVID-19 and a longer admission may be required to safe guard the wellbeing of the child.

Conclusion NAI is the tragic outcome of a complex interplay between the individual, relationship, community and society, and COVID-19 has accentuated the risk factors and compounded the complexity of the presentation. It must be a diagnosis which we seek to actively dismiss, to safeguard the children under our care, as it is often the failure to recognise the abuse that leads to the child’s demise. n

References References can be found online at www.boa.ac.uk/publications/JTO.

Features

Coronavirus (COVID-19): My experience of testing positive Kathryn S S Dayananda

After finishing the morning hand trauma list, I sat in the doctor’s office with my colleague, who was known to be high-risk. We were discussing the options on how to record and publicise the exemplary and timely changes we felt our unit had made in order to prepare for the coronavirus pandemic...

Kathryn S S Dayananda is a Specialty Trainee in Trauma & Orthopaedic Surgery for the Wales Deanery.

As a patient

As a colleague

I started to develop some nasal congestion and headache and decided to head home slightly earlier than usual. During the course of my 20-minute commute the headache progressed to such an extent that I went straight to bed. Within an hour I was feverish with flu-like symptoms. It was clear I was ill – was it the coronavirus or something else?

This was my longest period of absence for sick leave to-date having only had a total of 3-4 days off since qualifying in 2012. Although essential for my health and the health of others, being off work did not come easily or naturally to me.

I was desperately worried about my colleague. I messaged him urgently to let him know. I felt so awful for sitting with him despite distancing as much as possible. My symptoms progressed rapidly.

Prior to receiving my swab results I blamed myself for being lazy and inefficient with my time. I was frustrated at not being able to help out about the house or in work. I was exasperated by my inability to concentrate on anything.

“Most of all I worried about the staff, patients and public I could have infected without realising, especially my high-risk teammate and friend.”

I emailed, as per our local department guidelines, to enquire about testing and began the isolation process immediately. My husband kept away, slept in the spare room and used a separate bathroom. I had lost my appetite and had no energy to get up. I stayed in bed for three days. Gradually I developed a cough, although this wasn’t severe, and completely lost my sense of smell. I felt extremely achy and lethargic, suffered a vasovagal episode, and was short of breath despite minimal exertion. My resting heart rate had almost doubled and I was unable to undertake any activity in my home.

Gradually over the following 7-10 days I began improving, spending the majority of my time on the sofa resting. I received the call from Public Health Wales notifying me that my test was positive and wishing me a swift recovery.

Most of all I worried about the staff, patients and public I could have infected without realising, especially my highrisk teammate and friend. I felt extremely guilty that others would have to step into my on-call slots and other clinical commitments. I would say things like “I’m a team-player and I should be in work helping my friends and patients”.

As I began improving, I started to feel the cabin fever effects of isolation, yearning to get back to ‘normality’ and the dynamic hospital environment. Throughout my illness and return to work I have been fully supported by Consultants, colleagues and management. I returned directly onto the nightshift and the realisation that the hospital would be a very different place to how I left it soon dawned on me. I quickly caught up with a detailed Consultant lead handover. I found it reassuring to have at least a degree of immunity against the virus. I was

Features ward management have all been made readily available. A virtual mindfulness session has equipped us with strategies to remain composed in times of distinct uncertainty. The cohesive nature of the entire department and outstanding links with our orthogeriatric team have been second-to-none. It has made coming to work during these unprecedented times as stress free as possible.

Advice for colleagues We are here to help others when they can no longer take care of themselves. You must therefore make it your priority to look after yourself. Although for many of us it will go against our nature, you must take full rest when you need, for as long as you need. This can only be dictated by the individual. You have a responsibility to do this for yourself, for your colleagues and for your patients.

grateful to be back. I was able to interact with and support colleagues, help those in need, and do my part in the National fight against the invisible enemy.

“I hate being at home when everyone else is struggling at work” “I’d like to try and come for hand clinic Friday. Fingers crossed. And also get back to helping with on calls, because I hate being such a waster.” – Messages sent by Kat to her rota co-ordinator colleague while off work.

As a specialty trainee care provider When the news came that all elective operating would be cancelled, the gravity of the situation dawned on me. Within days our department had made huge logistical changes to the delivery of trauma service provision across Cardiff and Vale University Health Board. With strong leadership, tireless efforts from our Consultants and immense teamwork, the trauma theatre, fracture clinic and trauma ambulatory care unit (TACU) were redistributed to our elective unit on a separate site. Spinal, paediatric and polytrauma remained at our tertiary referral unit. This enabled a degree of containment of COVID-19 in the initial period, releasing beds, and supporting a restructuring of the staff rota. Two separate site rotas were devised to

prevent cross contamination from staff. It also compensated for the redeployment of non-consultant staff at all levels. These changes were encouraging for all trainees. It demonstrated departmental unity and care for each other. The creation of wellbeing boxes confirmed that our departments approach to tackling COVID-19 would be compassionate and charitable. It was reassuring to receive such topdown support. We all had three key concerns: patient and personal safety and training. Our Training Programme Director, (Mr Khitish Mohanty), gave thorough and clear advice in line with national recommendations regarding ARCPs and job rotations, which reassured us all. Virtual teaching was delivered where possible. Copious access to training sessions such as donning and doffing, medical management of the acutely unwell patient suffering COVID-19, and improving practical and logistical skills in

Don’t be fearful of accepting you don’t know. As well as providing trauma care, we are here to support specialties we have limited experience in. Many of us will be asked to perform tasks we are out of practice with or are unfamiliar to us. Be humble and ask for guidance and/or help. Like-wise you must go above and beyond to help others in your team, hospital and wider community when they need, ideally before they need to ask. Keep active. It will protect your mental and physical health. Try to be in-tune with your emotions. If you identify with increasingly upset feelings do not see this as failure. With increasing numbers of patients, staff, friends and family succumbing to this disease it is natural. Tackle them in the way that suits you, and if you’re not sure how to do this (none of us have lived / worked through a pandemic before) seek advice. Practice what you preach and do not take part in any unnecessary or risky activities. Avoid any non-essential travel. And if in doubt, “wear sunscreen”. (Baz Luhrmann) We wish you all good health and safe practising. From all at the T&O Department in Cardiff and Vale UHB. n

Features

An orthopaedic surgeon’s diary at the Nightingale Critical Care Unit Niall Eames

This is an extract from his COVID-19 diary, when he went with orthopaedic colleagues to help staff the Nightingale Critical Care Hospital in Belfast.

Monday 6th April 2020 The first Nightingale critical care unit opens in Belfast during the corona virus outbreak. Ortho surgeons volunteer to join nurses and medical colleagues there in the fight against coronavirus. 19 colleagues form the ‘nightingale platoon’.

Niall Eames is an orthopaedic spinal surgeon and Clinical Director of Orthopaedics and Spinal surgery in Belfast. He is a member of the BOA Education and Careers committee as well as being Chairman of the Spinal Training Interface Group. He has now finished his term as an examiner for the JCIE in Trauma & Orthopaedics. He is 53, married and has four children.

Over the weekend prior to opening we all visit the unit and receive briefings on how it works and what to do etc.

Monday 6th 2000hrs My first shift. It’s 12 hrs. I haven’t done a 12 hour night shift for an awfully long time - I worry I can get through it without falling asleep. Completely irrationally I cover my car insides in old sheets - maybe it will stop the virus getting onto the seats etc. Crazy notion. I haven’t worked in BCH since I was a surgical trainee in the early 1990s. A senior nurse, also being redeployed there, has given me a tip to bring my scrubs in a pillowcase. It was a great tip. It can simply go straight in washing machine when I get home. Arrive and met as planned by John at entrance foyer of hospital. The hospital is deserted. Car parks empty, except for staff arriving for night shift. I meet Pooler and Wu in car park - it’s reassuring to see familiar faces. We all carry our pillowcases. She must have told everyone this tip! John takes us to the changing rooms. We meet another anaesthetist who is wearing the oldest long green farming boots I have seen. What on

earth are those for I ask?! They will protect your ankles and feet he says - u will see. We gather in what is called the anaesthetic control room. The welcome is huge. We could not be made more welcome. They seem genuinely glad to have us along - we work together in theatres obviously, so there is an immediate bond. I have left my glasses in the changing room. A schoolboy error. Nerves I guess... John is an intensivist and our boss for the night. We are going to work in pods - mine has a consultant anaesthetist - an ENT trainee, an orthopaedic trainee, an anaesthetic trainee and me. Everyone is very friendly. It seems like first day at school - but clearly different. We receive a briefing from the day team now going home - a handover round. John comes across as so caring and professional. He obviously is completely on top of his game and immediately reassures us all. Each patient is carefully discussed. It is very real now. This is a very impressive group of clinicians running the unit. I wonder how on earth I can help them. Then it’s time to go to the unit. Pooler tells us he has heard that showers are dangerous because they vaporise the virus and it’s where people catch the disease. This is frightening. I had a plan to shower before I went home. I don’t know what to do about this, but there isn’t time to worry about it now. We move towards the room to get kitted up. It’s called the donning room. It is really strange - it’s the same room I worked in as a surgical trainee 27yrs ago - now it’s a security locked door into the new critical care unit.

Features Four of us are taken in together at a time to get all the PPE on. This is a bit scary. It’s clearly critical - the door is opened and we go in. Everything is laid out carefully in order - big large laminated sheets demanding how we will put each layer on. Everyone looks after each other. Our first job as a new team might be the most important one we do tonite! We check each other. The masks don’t feel that tight on my face. I wish it felt tighter. But it is the way it was fitted the day before by the technician and the testing machines said it was ok - have to trust it’s ok. The plastic gowns are flimsy - I wonder if they make a difference. I’m a big man. Everything feels tight, but it’s ok. There are boxes of PPE - that’s good. We write our names on stickers and put them on our visors or chest.

to touch them. It is really strange being in all these gear, to protect me. I am used to being in scrubs to protect patients - we usually can’t touch anything in operating theatres that isn’t sterile - this is now the exact opposite. Where do I put my hands? I feel like a medical student again.

John and Brenda take us on a ward round. There are a lot of patients. It’s hard to hear in the gear, but there is a dull noise of calmness about the place. In my normal job, scans and pictures tell me what I need to know about patients - here it’s numbers. There are numbers everywhere.

“The inner locked door is opened, and we go into critical care. I see patients in critical care as part of my normal job frequently. So I am used to it. But this is nothing like I have seen before. It is the same as TV. Everyone is dressed like me. You can only see their eyes. The stickers without names are vital now. It seems as if everyone is looking at the four people entering this space shuttle.”

My feet and ankles are uncovered except for my scrubs. They feel vulnerable. I see why some people wears boots. I will buy some. For the moment, I just must remember not

The inner locked door is opened, and we go into critical care. I see patients in critical care as part of my normal job frequently. So I am used to it. But this is nothing like I have seen before. It is the same as TV. Everyone is dressed like me. You can only see their eyes. The stickers with our names are vital now. It seems as if everyone is looking at the four people entering this space shuttle. It feels awkward. But that passes quickly.

We have all spent the last few days relearning these figures and what they all mean. Looking at the monitors and sheets - I take a deep breath and work my way slowly through what they all mean. Hopefully soon they will speak to me the way scans do! But not yet...

Gillian, the ENT trainee and I try and calculate some of the ratios we have learnt. It takes a few minutes, but we get there. The excitement of getting the result is very quickly overtaken by the realisation of what it means for the patient we are standing beside. These are very sick patients. As if we didn’t know. Brenda is brilliant with us. She explains all. I’m sure she is fed up already. A patient >>

Nightingale Critical Care Hospital in Belfast. (Image courtesy of the Department of Health).

Features We try and relax. I feel dirty. But I’ve washed my hands 7 times in the last 15 minutes. John sends us back in again in shifts. Some of my colleagues are on Level 2 of the tower, moving beds and ventilators about to prepare for the next surge of patients - if it comes. I wonder when it will come. Brenda tells us it’s on Twitter. Boris is being taken to ICU in London. That’s not good. We joke about middle-aged men being at risk. I look around. Wu says I’m not that old. I’m roughly same age as Boris.

A sketch made in Niall’s diary – the recognised orthopaedic tree supported by the stick, and the stethoscope representing critical care, to show our two services working in harmony during this crisis.

needs turned. We all help do that. The numbers are slowly beginning to make sense, but I know how to lift someone. After 2 hours, John tells us to leave. We have been in for long enough and he wants us to limit our viral load. So we are led out to the area where all the kit is taken off - the doffing area. This is where the virus really can get you. Everyone is ultra careful. Layer by layer we take it off. My glasses get caught. I recover. I need to be more careful.

“The nurses are very stretched. Many are new to ICU as well. Some only got phoned two hours before we started. John tells us to support them as much as possible. There are some tears around the place. People are stressed. He says to lighten the mood.”

Now in the control centre again we all sit awkwardly. What can you touch, what can’t u touch? Don’t touch my ankles. I wish I had boots. Food has been supplied by shops.

Again we go back in, following the same procedure of doffing. It feels easier the second time. When the doors open, it doesn’t feel so strange. We do another round of all the patients. The nurses are very stretched. Many are new to ICU as well. Some only got phoned two hours before we started. John tells us to support them as much as possible. There are some tears around the place. People are stressed. He says to lighten the mood.

Brenda and Tim are really good. They take time to explain all the stuff to us. Gillian understands it better than me, but it’s beginning to make sense. The next patients nurse I know - one

of our mph nurses. We punch each other in the chest, glad to recognise a familiar face. He’s such a positive guy. His patient is stable. Then I see two more nurses I know - again more punches and high fives. Brenda wonders what on earth she has let herself in for. At the next patient Brenda leaves Gillian and me for a moment to check something. As we stare at the charts and decipher the numbers, the nurse comes over to us. I don’t know her. She asks if all is ok - clearly worried we are finding a problem with her work. She doesn’t know who we are other than two new faces scrutinising her work. Her work is fantastic. I look at her and say - we are doing a handwriting check. Do you have your report card? She looks bemused. Were u not given a card? Well your writing is excellent. The three of us laugh. She is doing a fabulous job. We tell her that. The round continues. We move between areas. Bizarrely, an outside door opens rapidly directly beside us. Three cardboard boxes are slid across the floor at us, and the doors slam shut again! We look at each other. Must be the PPE arriving!! Nothing else to do but pick them up and carry them to the centre station. How do u pick up a box in full PPE gear?!? The clock on the wall hasn’t been changed to summer time. It’s an hour slow, but my heart drops a bit looking at it. I thought I was doing well until I saw it. John says it’s time for us to get out again. We duff our gear again - it’s easier this time. We head to the beds laid out in a nearby ward to grab some sleep. As I lie down I worry about my collar and ankles - they were exposed. I can’t sleep really. I worry I might touch them when I doze off. Boris is now ‘receiving oxygen’. I wonder what the truth really is... Morning arrives. I go and shower - but I worry now again. I trust Pooler and what if he is right. I drive home and strip off at the washing machine - everything goes in. I shower again. Back of my neck gets a special clean. It’s hard to cover up. Then go into my isolation room away from family. I sleep better now. The night had been ok. I hope my friends are all ok. I wonder how Boris is?

Night 2 It’s a beautiful day when I wake up. Had been sleeping well, until Amazon delivered a parcel. Go for a walk with Rosey and kids - beautiful day. Nature is alive and happy. Time to go back in again. I change into tracksuit again. It has shrunk in wash. Now sits some way up my shins. I look a fool. Who cares. The same cycle starts again. Handover. Doning, doffing. n

Features

Orthopaedic care changes since the B.C. (Before COVID-19) time period Mary Campbell, Andrew Hughes, Brendan Daly, Aedín Hanahoe, Darren Moloney, Iain Feeley, Eoin Sheehan and Khalid Merghani Published as an update to ‘Orthopaedic social distancing and manpower management throughout COVID-19’ https://www.boa.ac.uk/policy-engagement/journal-of-trauma-orthopaedics/journalof-trauma-orthopaedics-and-coronavirus/orthopaedic-social-distancing-and-manpower.html. Published on TJTO&C 30 March, 2020.

Mary Campbell is graduate from University College Dublin who is currently an intern at Midlands Regional Hospital Tullamore.

Andrew Hughes is an ST6 Specialist Registrar in trauma and orthopaedic surgery.

Brendan Daly is a UCD School of a Medicine graduate and currently an orthopaedic intern in Midlands Regional Hospital Tullamore.

he COVID-19 pandemic has posed unprecedented challenges to health systems, both globally and domestically, and within the Irish healthcare system itself. Since the WHO declared the COVID-19 pandemic on 11th March 2020, the Trauma and Orthopaedic Surgery Department in Midlands Regional Hospital Tullamore, Co Offaly, has introduced practice modifications so as to ensure a safe working environment, whilst maintaining care standards for our patients and the wider community. Such changes are likely to persist beyond the current climate, as we rapidly embrace innovation and technology.

to a neighbouring hospital. All patients require a negative COVID-19 swab result prior to admission, so as to minimise risk. Patient flow has thus been reduced in the acute hospital setting. Traditional trauma clinics have been ‘virtualised’ via the Trauma Assessment Clinic, or virtual fracture clinic, a pathway that exists between the three Midlands Hospitals2. Inclusion criteria have been expanded to include all trauma cases, such that the capacity of the virtual clinics have increased by over 60%. Patients requiring clinical review are seen later that same afternoon. The weekly trauma conference has taken the form of a teleconference, with all consultants and NCHD’s remotely accessing a shared presentation, narrated by the in-house trauma team on call. A website, as well as a social media platform, has been created by the Department, to provide patients with reliable information and injury-specific advice. Morning ward rounds have been condensed to two registrars and one intern. There are currently 13 members of the orthopaedic team, and morning round attendances are rotated between members who have completed full mandatory PPE training.

“Since the WHO declared the COVID-19 pandemic on 11th March 2020, the Trauma and Orthopaedic Surgery Department in Midlands Regional Hospital Tullamore, Co Offaly, has introduced practice modifications so as to ensure a safe working environment, whilst maintaining care standards for our patients and the wider community.”

Service provision has been streamlined over the past two months, so as to limit footfall within the hospital and reduce exposures for our patients, most of whom fall within the ‘vulnerable’ category. In line with the WHO guidelines for infection prevention and control of pandemic-prone acute respiratory infections (2007), all elective orthopaedic surgeries and elective outpatient department sessions have been cancelled1. Ambulatory day-case trauma surgery has been transferred

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Aedín Hanahoe is a graduate from NUIG and is currently an orthopaedic intern in Midlands Regional Hospital Tullamore.

Darren Moloney is a CST2 in trauma and orthopaedics currently practicing in Midlands Regional Hospital Tullamore. Darren has a keen interest in research focussing on novel surgical techniques in trauma surgery.

“In line with the WHO guidelines for infection prevention and control of pandemic-prone acute respiratory infections (2007), all elective orthopaedic surgeries and elective outpatient department sessions have been cancelled. Ambulatory day-case trauma surgery has been transferred to a neighbouring hospital. All patients require a negative COVID-19 swab result prior to admission, so as to minimise risk.” Core orthopaedics is preserved and allows redundancy in the staffing system to allow redeployment (at times redeploying to our medical colleagues who are actively treating COVID-19 positive patients, relieving healthcare workers who have been advised to self-isolate). Modifications of the consultant and registrar rota allows a senior decision maker to be on the front line at all times. With national social isolation and ‘cocooning’ there has been a reduction in trauma referrals. The fall-off in trauma coupled with the cancellation of elective surgeries has created a level of redundancy in orthopaedic staff commitments. This has allowed one consultant each day to maintain a daily administrative liaison roll. This consultant has no clinical duties and is available to attend, advise and receive regular updates from the hospitals ‘COVID Management Team’.

The orthopaedic consultant body conduct an evening videoconference for handover and dispersal of information relating to the day’s events. The meeting is scheduled after normal working hours to facilitate a full complement of consultant staff. The meeting is led by the lead administrative consultant on that day and follows a set ‘constant agenda’. This meeting updates all senior members of the team and allows consensus and seamless decisions when engaging with management and other clinical stakeholders. A briefing and debriefing are performed with consultants via videoconference, discussing the caseload and escalation plans. This avoids differing opinions regarding patient management when patients present under a different consultant and team for scheduled trauma surgery. A consensus opinion regarding envisaged management for trauma patients is attained by the consultant >>

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Iain Feeley is an ST6 Specialist Registrar in trauma and orthopaedic surgery.

Eoin Sheehan is an Orthopaedic Surgeon in Tullamore Hospital and is the National Training Programme Director for T&O. He practices in hip and knee arthroplasty having been fellowship trained at the Rothman Institute in Philadelphia. He is also an Adjunct Professor Orthopaedics, University Limerick.

Khalid Merghani is an Orthopaedic Consultant at Midland Regional Hospital Tullamore. He is a member of the Irish Institute of Trauma and Orthopaedics (IITOS). Interest in computer navigated and robotics arthroplasty, soft tissue knee surgery, virtual/augmented reality training and modernisation of medical practices, completed higher training in Orthopaedics in Ireland and Fellowship trained in Australia.

team courtesy of this daily meeting. This also allows a cohesive approach for the team when dealing with the rapidly changing fluid environment of information and updates relating to COVID-19. In a situation where a team member is a confirmed close contact to a COVID-19 positive patient, strict precautions have been taken under the advice of occupational health, which may require 14 days of self-isolation with close symptom monitoring. This, though effective in protecting both staff and patients3, can unfortunately have a negative effect on staff morale, often leading to guilt and anxiety regarding sick leave. Studies have shown that under normal circumstances, doctors have a relatively high rate of sickness presenteeism (82%), with the main reason for working through an illness being “not wanting to burden other colleagues”4. The resultant negative effect on staff morale and mental health must be considered, and thus the Healthcare Worker COVID-19 Helpline5 has been welcomed. Now, more than ever, occupational health guidelines must be strictly adhered to. Exposure risk must be carefully weighed up against feelings of truancy amongst staff during this pandemic state. Strict measures are required in order to safely deliver high quality care to our vulnerable patients, whilst decreasing the risk of COVID-19 transfer between the hospital and community. Cancelling elective activity, virtualising trauma clinics and teleconferencing are measures that have been taken in our department over the past two months. These testing times require creativity, determination, resilience and support within teams so as to maintain standards, whilst mitigating risk. COVID-19 has been described as

a “disruptive accelerator”, such that its negative effects on our healthcare system have resulted in rapid progress in changing our approach to the delivery of care. Never before has there been such a pivot in the way we practice orthopaedics. We are becoming increasingly less likely to return to how we managed our daily practice B.C. (before COVID-19). It has been quick, but in this current crisis “speed trumps perfection”. n

References 1. Chang Liang Z, Wang W, Murphy D, Po Hui J. Novel Coronavirus and Orthopaedic Surgery. J Bone Joint Surg Am. 2020 Mar 20. [Epub ahead of print] 2. O’Reilly M, Breathnach O, Conlon B, Kiernan C, Sheehan E. Trauma Assessment Clinic: virtually a safe and smarter way of managing trauma care in Ireland. Injury. 2019;50(4);898-902. 3. Arabi Y, Murthy S, Webb S. COVID-19: a novel coronavirus and a novel challenge for critical care. Intensive Care Med. 2020;46(5):833-6. 4. Tan PC, Robinson G, Jayathissa S, Weatherall M. Coming to work sick: a survey of hospital doctors in New Zealand. N Z Med J. 2014;127(1399):23-35. 5. Health Service Executive. Staff: minding your mental health. Available from: https://healthservice.hse.ie/staff/news/ coronavirus/staff-minding-your-mentalhealth-during-the-coronavirus-outbreak.html. Accessed 26 March 2020.

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Commentary on the Swansea Hip interrogation Fracture Tool (SHiFT)

– article originally published in the Transient JTO & the Coronavirus Michael Cronin, Mark Mullins, Praveen Pathmanaban, Paul Williams and Matthew Dodd

We were informed by Swansea Bay University Health Board (SBUHB) on the 31st March 2020 to expect 2,000 COVID-19 admissions, 200 critical care admissions and 200 CPAP patients over the coming two weeks. The pandemic was about to expose our health care systems to extraordinary clinical scenarios, stretch resources and raise challenging ethical dilemmas that many had never previously faced.

he time sensitive nature of decision making in an evolving crisis, inevitably results in some local and national guidance becoming outdated before it is even published, but should not be used as an excuse to absolve responsibility. Is it better for Clinicians to act thoughtfully and transparently, reviewing their decisions, than to be paralysed by inaction or the fear of being wrong?

Although never formerly implemented, we have been invited in a future publication to reflect on the SHiFT as a potential mechanism for ceiling of care decision making; a critique of the scoring tools used; the removal of the community component of the pathway; and a review of our Proximal Femoral Fracture patients treated during the pandemic.

“Planning appropriate healthcare during a pandemic is something that we found uncomfortable, both in understanding the recommendations of published pandemic guidance and in consideration of implementing change.”

Learning the lessons by reviewing decisions made responding to one pandemic, prove of greater value in planning the management of another, or indeed of a subsequent second wave.

However, this brief commentary is not to justify our work but to encourage reflection and open discussion around the ethical dilemmas raised whilst the pandemic continues its uncertain path.

We remain of the opinion that developing a tool and disseminating it openly to a wider audience for immediate peer review is preferable to acting in a closed and clandestine manner. The ethical dilemmas are clear and numerous for our patients.

They have been mirrored across many other specialities, with the prioritisation of COVID-19 over urgent cancer surgery being just one other stark example. Planning appropriate healthcare during a pandemic is something that we found uncomfortable, both in understanding the recommendations of published pandemic guidance and in consideration of implementing change. We remain grateful to the SBUHB Clinical Ethics Committee for providing advice and support in helping us to address many of the difficult issues. On further ethical discussion, we realise our concept was not pure ‘utilitarian’ but an approach to promote ‘maximum net benefit’ alongside close consideration of individual need. This is no different in principle from what we do in more normal times but when capacity is much more limited more weight has to be given to questions of who gets what. The work was borne partly out of the ethical dilemma created, following COVID-19 restrictions on theatre capacity, which remains outside of our control. We were fully cognisant of the ramifications of pursuing this path of publication and peer review and the potential unease that it could create within our community. We welcome further scrutiny and discussion of this going forward. However, if we are to truly benefit from reflection and hindsight, it would be better to not simply criticise but decide if the underlying ethical principles are correct. The discussion should not be solely around what you would do to prevent your department from ever being in this position, but, what you would do once all other options have been exhausted. This is the only way we may be better prepared for a potential second wave or future pandemic. n

By your side throughout the COVID-19 crisis For over 125 years we have supported members through both the good times and the bad Whatever challenges you may face, now and in the future, we will continue to be here for you. • Our discretionary approach means we can be flexible, adapting to emerging risks and providing the comprehensive protection members need • Our members have the largest team of medicolegal experts in their corner • As a mutual organisation, we always put the needs of our members first We’re here for you in these uncertain times. Stay safe, support each other and we will get through this together. Dr Rob Hendry Medical Director

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COVID-19 causes a SHiFT in the sands for proximal femoral fracture management? Michael Cronin, Mark Mullins, Paul Williams, Matthew Dodd and Praveen Pathmanaban

“It is not surprising that in talking about uncertainty we should lean heavily on facts, just as the court of law does when interrogating witnesses. Facts form a sort of bedrock on which we can build the shifting sands of uncertainty.”1

oted statistician Dennis Lindley is quoted in his text ‘Understanding uncertainty’ which discusses how virtually every aspect of our lives involves situations in which the outcomes are uncertain and how best to deal with them.

Michael Cronin is a Consultant Orthopaedic and Trauma Surgeon with a specialist interest in hip preservation surgery. He is currently the National Joint Registry lead for Swansea Bay University Health Board.

Mark Mullins is Consultant Orthopaedic and Trauma Surgeon specialising in hip and knee arthroplasty surgery. He is currently the clinical lead for orthopaedics for Swansea Bay University Health Board.

The advent of COVID-19 has led to major uncertainty in all aspects of our lives. The current shifting sands in our specialty reflect this with a plethora of guidance documents and advice being produced by our peer bodies. In the face of COVID-19 the GMC and BOA2 have written to support the need for pragmatism and alterations in our practice for clinical decision making on an individual patient basis.

The Swansea Hip interrogation Fracture Tool (SHiFT) has been devised to enable clinical decision making in this extremely ethically and morally difficult area.

Background Swansea Bay University Health Board (SBUHB) experiences a large annual volume of patients with a proximal femoral fracture (fractured neck of femur or #NOF). On an annual basis we treat between 500-600 proximal femoral fracture cases running a 12 hour trauma list seven days a week, alongside 1-2 emergency ‘CEPOD’ theatres.

“In the face of COVID-19 the GMC and BOA have written to support the need for pragmatism and alterations in our practice for clinical decision making on an individual patient basis.”

Patients with a proximal femoral fracture are arguably the ‘bedrock’ of our Trauma practice. But when it comes to interrogating the ‘facts’, for any individual case, how will we actually make these decisions in practice and how will the ‘court of law interrogate us as witnesses’ in the future when the COVID-19 tsunami has dispersed?

Interrogation in social science terms means to ask questions about something as a way of analysing it or finding out more about it to enable the decision making process. In particular for this patient group, it can be used to help us decide how best we should treat them.

Our hospital covers a population of 390,000 patients and routinely operates 20 operating lists a day. Since the Government’s call to prepare for the anticipated surge of COVID-19 cases, the hospital has diverted much time and resource into retraining staff and reconfiguring clinical areas. For the last two weeks, capacity in SBUHB has been severely reduced down to two emergency ‘CEPOD’ theatres to accommodate life and limb threatening surgery only. One theatre runs 24 hours a day, the other only 12 hours. The Health Board have taken the decision to treat all operative cases as potentially COVID-19 positive. All theatre personnel are wearing PPE for aerosol generating procedures (AGP)3,

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including all proximal femoral fracture cases with FFP3 or N95 masks being worn by all staff. Each case is now taking two to three times longer to perform because of the PPE procedures and COVID-19 protocols required.

Paul Williams is Clinical Director for T&O and spinal surgery in the Swansea Bay University Health Board and a Swansea Medical School clinical tutor and examiner. Specialty interests are paediatric and adolescent orthopaedics and foot and ankle surgery.

PPE stocks across theatres, ITU and the hospital in general are limited. However, we are being correctly advised by the Royal College of Surgeons that protecting ourselves and our staff is a priority. This has not yet led to any significant delay in treatment but placing all of these facts together means the realistic throughput of proximal femoral fracture cases has been significantly reduced. It is against this background that all surgical specialities within SBUHB are being asked to try and determine whether all patients still appropriate for theatre or whether some could be managed conservatively. The magnitude of unintended consequences on patient outcomes, morbidity and mortality, in non-COVID-19 medical and surgical conditions is difficult to quantify but will likely be detrimentally affected by the current approach.

Matthew Dodd is Consultant Orthopaedic and Trauma Surgeon specialising in hip and knee surgery with interests in sports injuries and the young adult hip. He is the hip fracture lead for Swansea Bay University Health Board.

Praveen Pathmanaban is a Consultant Orthogeriatrician at Singleton and Morriston Hospitals (Swansea Bay University Board).

In 2005/06 the UK treated 68,000 proximal femoral fracture patients, with mortality being 10% at 30 days, 20% at four months and 30% at one year after admission4. The overall figures have continued to grow but since the National Hip Fracture Database (NHFD) and the introduction of best practice tariff, the national mortality figures have reduced. In a time of limited resources we have attempted to rationalise the care we provide for this large group of patients by developing a pathway and clinical decision making tool for treatment. Underpinning this process are the following principals:

• Decision making needs to be made collaboratively between Trauma and Orthopaedic surgeons and Orthogeriatricians. • Accepting that the implementation of the pathway is likely to lead to an increase in conservative care of patients.

Methods The aim was to make an objective scoring system that was reproducible, robust and could be used to help make informed decisions based on predicted patient outcomes. The Nottingham Hip Fracture Score (NHFS)5 is a ‘disease specific’ score that can be used to compare groups and predicted mortality. The Clinical Frailty Scale (CFS) is a ‘generic’ score which has been used extensively in COVID-19 patients as a way of helping stratify patients into groups with different ceilings of care. The combination of a disease specific and generic score appear to be a good way of interrogating information about predicted mortality and patients pre-morbid function/ Quality of Life. The Swansea Hip interrogation Fracture Tool (SHiFT) is a simple addition of the NHFS + CFS and is designed to be used to aid in clinical decision making and triage. The minimum score possible is four and the maximum is 19. We have reviewed our patient cohort from Q1 2019 to assess the suitability of the tool for patient triage and decision making. Our suggested decision making algorithm would divide inpatients into three groups, see Figure 1. >>

• To continue to provide surgery for as many patients with a proximal femoral fracture as capacity will allow. • The decision whether a patient requires surgery will be made on objective clinical grounds. • The benefits and risks of hospital admission and surgery will be balanced with the additional risks to the individual patient due to the COVID-19 pandemic. The potential risks to others such as staff and fellow residents on return to residential and nursing home accommodation must also be taken into consideration.

Figure 1: Potential inpatient groups.

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Between 1st January and 31st March 2019 we admitted 124 proximal femoral fracture patients. Their SHiFT scores ranged from six to 15 with a whole group mortality of 26%. We further subdivided the scores into three groups in an attempt to make three separate treatment pathways, see Table 1. Score

Number

Percentage of patients

Mortality (4 month)

4-8

34%

9-12

56%

34%

13+

10%

58%

Table 1: Retrospectively calculated SHiFT scores between 1st January and 31st March 2019.

The rationale would be for any individual hospital to look at their scores and case mix to decide on the size of the three groups. For example, if we wished to increase the frailest group, we could change the threshold to 12+. This would change the figures as shown in Table 2. Score

Number

Percentage of patients

Mortality (4 month)

4-8

34%

9-11

39%

27%

12+

27%

53%

Table 2: Retrospectively calculated SHiFT scores between 1st January and 31st March 2019 with threshold changed to 12+.

During times of significantly low capacity (the current COVID-19 pandemic is one example), the score will be used as an objective measure to ensure the patient population is treated in order to maximise survival and quality of life. We have chosen to only introduce these tools once we have an ‘anticipated prolonged’ reduction in capacity to below 20%. These threshold decisions need to be made at an individual hospital level based on a local understanding of capacity and demand. Patients are to be listed in order of score (lowest first or ‘fittest first’) on any given day. The number to be listed depends on predicted maximum capacity (plus an extra case on standby). Patients with higher scores may never get to the top of the list depending on number of cases presenting and capacity available. At seven days a further review will be undertaken to assess ongoing suitability for surgery based on:

Figure 2: Non-operative treatment pathway.

Assessing whether the patient is COVID-19 positive will significantly affect the decision to operate or to treat non-operatively depending on the clinical status and the anticipated length of wait for surgery. Patients medically compromised by COVID-19 will be treated nonoperatively. The complete pathway including the thresholds we have chosen is shown in Figure 3. For patients in institutional care the intention is to screen the patients to reduce unnecessary admission to hospital. The attending health care staff will be told to telephone a triage number where a discussion can take place to establish the SHiFT score. For the NHFS, the Haemoglobin will be assumed to be greater than 10 g/dl equating to a score of zero (although clearly this could change to a score of one at a later stage if admitted).

• Ongoing clinical need (Still in pain and immobile). • Clinical status (Still anaesthetically fit). • Present theatre capacity. It is envisaged that at seven days remaining patients will be converted to the non-operative group. Patients in the non-operative group will follow a defined protocol as shown in Figure 2.

Figure 3: COVID-19 in hospital proximal femur fracture pathway.

If the score is greater than or equal to 13 the recommendation would be to advise nonoperative management for the patient and therefore try to avoid admission to hospital. We accept that within this group we will only be able to treat a small proportion of patients in their own home/NH. We therefore propose to otherwise transfer these patients to a ward area on a non-acute hospital site for conservative management. For scores of 12 or less the patient should be transferred to hospital where the patient can be assessed by the Orthopaedic Trauma team in the ambulance. There would be an opportunity to discharge the patient back to their usual point of care or transfer to our non-acute ward if the SHiFT score is found to be 13. If the patient is deemed fit they will be admitted to hospital with an intention to operate.

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is Executive level understanding that these decisions are being made in the interest of the more global picture within the Health Board.

Suspected #NOF COVID19 Pathway Fall at home or Nursing Home

Non Weight Bearing, Elderly >65

999 Call to WAST

TRIAGE CENTRE using triage tool – Clinical Frailty Score + Nottingham Hip Fracture Score Registrar On Call – Cisco Phone No: 23576

Combined Score 13 or more

Combined score 12 or less

Remain in home or Nursing home or Transfer to non-acute hospital site Analgesia Follow out of hospital management NOF guidelines Contact by Nurse practitioner within 72 hours Liaise with Community and Primary Care Services

AMBULANCE TO MORRISTON

Assessed by senior T&O On Call on board ambulance To confirm triage tool outcome

Admit

Discharge in same ambulance with FU

Return to home or Nursing home or Transfer to non-acute hospital site Analgesia Follow out of hospital management NOF guidelines Contact by Nurse practitioner within 72 hours Liaise with Community and Primary Care Services

Figure 4: COVID-19 Pre-hospital pathway.

The pre-hospital pathway is shown in Figure 4. Work has been performed in primary care with GPs and Clusters as part of the COVID-19 preparations to get Advanced Care Plans in place for residents of residential and nursing homes to enable clinical decision making. For patients who are not admitted to hospital a Nurse Practitioner contact review is arranged 48-72 hours later. All patients will require adequate analgesia. A full out of hospital treatment protocol is being worked on as a separate document. Accurate documentation regarding the scoring process and decision making must be undertaken with the clinicians involved named and their GMC numbers annotated. A decision should be made and documented on admission as to whether the patient is for DNA CPR or otherwise. This conversation may be made easier using the excellent advice recently published on dealing with this topic specifically to COVID-19 patients6. Family members should be informed of the management plan, even if this must be done remotely by telephone. Clinical judgment must guide treatment at a local level. There

Weekly review of the figures will be performed to ensure the group sizes are correct to match capacity. However, we do not envisage changing the threshold levels to match capacity on a day to day basis as this would cause inconsistency in the approach with patients and add a level of confusion in the system.

Discussion

Data from the UK National Hip Fracture Database (NHFD)7 in 2013 indicated that 2.6% of patients with fractures of the femoral neck are treated by conservative means. Although it is often thought that patients undergoing non-surgical management have worse outcomes both Moulton et al.8 and Gregory et al.9 have provided evidence to support the non-operative management of some patients with intracapsular fracture. Handoll et al.10 performed a Cochrane review most recently updated in 2008. This included four studies on extra-capsular fractures and concluded no difference in medical complications, mortality and long-term pain between operative and non-operative groups. However, they did find that surgery resulted in higher rate of healing, better leg length, shorter length of stay and higher chance of return to their original residence. We use the above evidence and national guidelines to justify surgery on a daily basis. However, we must be acutely aware that all of these conclusions are based on healthcare systems where capacity is not outstripped by demand. It may appear we are pushing against the tide of conventional wisdom for our patients but, these changes are not without good reason. As doctors we are all taught to do what is in the best interest of the patient in front of you.

However, an ethical dilemma comes when we are being forced to sacrifice normal service capacity to ‘plan’ for the COVID-19 pandemic, the size and effect of its peak, still unknown. Once the decision was made centrally to essentially act in the best interest of the entire population, we as clinicians are no longer able to do what is in the best interest of a single patient in front of us. We have to do what is in the best interest of the whole population we serve. With the limited capacity we now have available for treating our proximal femoral fracture patients we have to decide whether we treat everyone in a new way, giving up our normal model of ‘sickest first’ to a new model of ‘fittest first’. If we cannot treat all should we treat those most likely to survive and those likely to regain most quality of life? This ethical dilemma was discussed in the World Health Organisation global consultation on pandemic planning in 200611. Within it clearly states that “the principle of utility, that is, acting so as to produce the greatest good is valid even if it means bringing greater good to a small number of people than a smaller good to a larger group”. The NHFS and the CFS both confirm that patients with higher scores have higher mortality and poorer pre-morbid quality of life. Combining the two scores to give the SHiFT score at this time of the COVID-19 pandemic and its wider implications, appears to provide a logical method to support a shift towards preventing hospital admission and non-operative management in certain individuals with a fracture neck of femur. The situation we find ourselves in at SBUHB will not be unique. Interestingly, our Health Boards decision on 27th March 2020, to treat all patient as COVID-19 positive in theatre was well before many other parts of the country, who have now adopted this policy. The rapidly changing understanding of the pandemic itself is mirrored by a rapidly changing understanding of the implications it has on our remaining practice.

Conclusions In these times of COVID-19 uncertainty, interrogation of the evidence surrounding the management of patients with a proximal femoral fracture and application to individual hospitals clinical circumstances indicates that non-operative management may be more justifiable than we once thought. Only when the sands have stopped shifting will we perhaps understand fully to what extent. n

References and Appendices References and Appendices can be found online at www.boa.ac.uk/publications/JTO.

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A letter in response to: COVID-19 causes a SHiFT in the sands for proximal femoral fracture management? A plea for caution Peter M Lewis, Miriam Day, Lisa A Williams, Laura Lougher, Glenn J Clewer and Stephen Sarasin Letter originally published 22 April 2020 in response to the article: COVID-19 causes a SHiFT in the sands for proximal femoral fracture management? https://www.boa.ac.uk/policyengagement/journal-of-trauma-orthopaedics/journal-of-trauma-orthopaedics-and-coronavirus/ covid-19-causes-a-shift-in-the-sands-for-proximal.html. Published in TJTOC&C 17 April 2020.

We read with interest the article written by the Swansea orthopaedic surgeons with regard to the treatment of patients with a fractured neck of femur (FNOF) during the present COVID-19 virus crisis1. Although this endeavour is to be congratulated on a ‘be prepared for the worst’ basis, we have considerable reservations with their conclusions and therefore its use.

he Swansea team offer a scoring system for Trauma and Orthopaedic departments in UK hospitals to use in patients with a FNOF and provides treatment protocols to be undertaken either within the hospital or with patients remaining based at home. Their scoring system, abbreviated SHiFT (Swansea Hip interrogation Fracture Tool), offers a scoring tool to determine if patients warrant surgery or conservative management. We therefore ask the question firstly, is this scoring system indicated at present because of the serious and severe shortage of beds/ surgeons/operating lists etc. and secondly, is this SHiFT scoring system supported by the established orthopaedic literature. Firstly, of significance, on the 16th April 2020 Chief executive of NHS Wales Dr Andrew Goodall warned against waiting too long to seek emergency treatment or choosing not to access regular services at the present time2. He stated,

although understanding services are disrupted “I am concerned people may not be seeking medical help for illnesses and symptoms not related to COVID-19”. He reinforced the message that “urgent and emergency services for both physical and mental illness are still open and accessible”. Therefore, thankfully at present, although elective operating lists have been cancelled, emergency lists for life threatening conditions can continue. Of relevance to patients with FNOF, A&E emergency attendances are currently 60% down compared to this time last year and ambulance arrivals reduced by 20%2. ‘Patient activity’ for GPs has also fallen by 25% lower than usual. Furthermore, all Health boards in Wales are reporting a ‘green’ status, and with around 49% of their critical care beds remaining vacant with only one in three occupied with a Coronavirus patient2. Although staff sickness is increased during this pandemic to 9.2%, the average for this period is 5%. In conclusion, at least in Wales, there is at present

no requirement for such a triage system and patients with FNOF should continue to attend hospital on an urgent basis. With regard to the second question, namely does the SHiFT scoring system help in prioritising those patients who can be operated upon and leave others better treated by a conservative approach? Patients with FNOF are a surgical emergency with universal acceptance, nationally and internationally, that the standard of care should be an operation undertaken within 24-48 hours of admission3, and with recommendations in the UK remaining the same during this current COVID-19 crisis4. In an extensive recent review article published by one of the senior authors of this response, it states, “unless a patient is likely to die rapidly, any patient with a fracture of the hip should undergo surgery. The patient is out of severe pain and can be nursed comfortably in a dignified fashion”3. Does this remain true during a pandemic crisis? The SHiFT system itself is an extension to the Nottingham Hip Fracture Score (NHFS)5 which is a validated predictor of 30-day mortality for patients undergoing hip fracture surgery along with the addition of a Clinical Frailty Scale. The resultant Swansea scoring system was then validated by a study by the authors over the three winter months of 2019. Not unsurprisingly, the greater the patient frailty, in addition to their NHF score, the greater the 30day mortality identified (up to 58% in certain patients). With minimum score of 4 and maximum of 19, the SHiFT system stratified patients into three groups, being Surgery, Potential Surgery and Non-operative, with the fittest patient always undergoing operation first. Those falling into the intermediary group, if failing to receive surgery within the first seven days, it is envisaged following a further review, they will then be transferred to the

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non-operative group. The authors propose scores also be undertaken for those at home/ institutional care with intention to screen and avoid admission to an acute hospital site should an operation be deemed ‘inappropriate’. On review, this SHiFT score validation study, involving only a small number of patients, was undertaken prior to the current pandemic crisis and with the advantage of patients all being diagnosed, medically reviewed and surgically treated within the hospital. Staff were not compromised with the present social distancing requirements and now during the pandemic, an understanding that any resultant increased burden to primary care will predominantly need to be provided via virtual/telephone consultations. The SHiFT system does envisage a significant number of patients being treated non-operatively, either at hospital or remaining in their place of residence. Is this safe and acceptable care? A limited literature review was undertaken to support their policy. It includes a Cochrane review published in 20086, which itself contained only five RCTs, involving 428 patients, and only one of which considered unbiased and related to current practice. The paper in question7, published in 1989 (30 years ago), classified patients as ‘elderly’ when aged over 60! 106 patients were randomised to either tibial skeletal traction or Dynamic hip screw. Conservative/

traction management resulted in a mean 27-day longer length of stay, with more patients still in hospital at six months and greater loss of independence. In our opinion, such lengthy hospital stays, bed blocking and requirement for 24 hours of nursing care, is unacceptable to even be considered during a pandemic crisis. Two further papers were used to support the Swansea protocol; both concluding ‘acceptable’ outcomes following conservatively managed hip fractures. The first8, a retrospective review 32 patients, revealed a 30-day mortality of 31.3% and at one year 56.3% with 18 patients at the time of discharge reported as pain free or controlled with analgesia. The second paper9, was prospective, including 22 patients treated conservatively over a one-year period had a 30 day mortality of 32% (7/22) and by one-year 50% (11/22). A repeated ‘dynamic evaluation’ policy was however undertaken for all conservatively managed fractures and some of those with ASA four still went on to require surgery for severe pain. In our opinion, these papers again do not support a conservative approach for the FNOF patient, many of whom will be in significant pain and with requirement for prolonged medical and nursing care- quite in contrast to what is required during this pandemic crisis. Lastly, the SHiFT system proposes high scoring patients should remain at home/nursing home.

Inevitably such patients are open to misdiagnosis (periprosthetic fracture, malignancy, diaphyseal fracture etc.), with limited facility for pain relief and/or ‘dynamic review’. Those patients reaching hospital and triaged via SHiFT into the unfortunate intermediate group for ‘potential surgery’, will be serially starved and with inevitable associated pain, distress and increased risk of COVID-19 infection awaiting possible surgery. Should they reach seven days without surgery it is ‘envisaged’ they convert to non-operative care despite prior explanations and consent. In conclusion, The Royal College of Surgeons describe a potential pandemic situation when facilities and staff are stretched “beyond the edge”10. Inevitably should this occur, this will result in a compromise to all levels of care. In such a situation the SHiFT triage system may present valuable prognostic information. We have not reached this stage. The literature confirms the FNOF patient is reliably managed with surgery, with less postoperative demands of nursing and social care, shorter length of stay and greater long-term independence. It should remain the standard of care until circumstances deteriorate and demand otherwise. n

References References can be found online at www.boa.ac.uk/publications/JTO.

15th Trauma & Orthopaedics Update Val d’Isere, 1-4 February 2021

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Features

A response to the letter by Lewis et al. from the authors of: COVID-19 causes a SHiFT in the sands for proximal femoral fracture management? Michael Cronin, Mark Mullins, Praveen Pathmanaban, Paul Williams and Matthew Dodd

Letter originally published 22 April 2020 in reply to: A letter in response to: COVID-19 causes a SHiFT in the sands for proximal femoral fracture management? A plea for caution. https://www.boa.ac.uk/policy-engagement/journal-of-trauma-orthopaedics/journal-oftrauma-orthopaedics-and-coronavirus/a-letter-in-response-to-covid-19-causes-a-shift.html.

We welcome the opportunity to reply to the letter by Lewis et al. in response to our paper. We hope our response not only answers the questions raised but also manages to clarify the ethical dilemmas the article was attempting to raise.

e agree entirely with ‘a plea for caution’ and wish to stress at the outset that a decision to not operate on a patient with a proximal femoral fracture flies in the face of the traditional dogma and as such challenges every Orthopaedic cell in our bodies. It is not a discussion that was taken lightly and has been discussed thoroughly with the Health Boards Ethical committee. We hoped to raise two ethical discussions and now realise that we need to elaborate on these for the process to be fully understood. The first ethical dilemma is how we treat patients in a healthcare system where capacity is significantly outstripped by demand. We hope that this situation never occurs in any Health Board but it is surely essential that you

have thought about how you would deal with it, if it ever were to occur. In answer to your first question, “Is the scoring system indicated at present because of a serious and severe shortage of beds/surgeons/operating lists etc.?” As stated, the protocol would only be used in an extreme situation where capacity fell below 20% (an arbitrary figure to be debated locally). We had hoped that readers would have assumed that as Doctors we would exhaust all options to improve this capacity. We have optimised internal staffing models and attempted to recruit extra staff internally. We have investigated extra internal HB capacity such as Singleton and Neath Port Talbot Hospitals, but they rely on the same staff pool. We are constantly exploring

the option of extra capacity from neighbouring Health Boards and have been given some access for ambulatory trauma but not Proximal femoral fracture patients. We have even suggested to the Health Board that a final option would be to ‘close’ the Orthopaedic on-call in SBUHB and divert ambulances to neighbouring trusts, we are yet to receive a response. If despite these measures, any hospital was to be in a position where you CANNOT treat all of your patients, how would you plan to decide on who to treat? Would you still try and treat them all, admitting that the mortality rate for the whole group would be significantly raised? Using data from the last three weeks, had we been reduced to 20% capacity, by day 14, all patients would be waiting nine days for surgery and rising on a daily basis, with the potential COVID-19 tsunami still yet to arrive. The ethical argument used for healthcare systems where demand significantly exceeds capacity is that of Utilitarianism. As discussed in the original paper, treating the population for the ‘greatest good’ remembering that this is not where we want to be but where we may be in extreme situations once everything else has been exhausted. These decisions must of course be revisited on a regular basis and any daily change in capacity used as efficiently as possible. The ethical argument of utilitarianism in pandemic medicine planning is probably the hardest concept to grasp and accept. The concept of treating ‘fittest first’ goes against every aspect of our normal proximal femoral fracture evidence and practice. This concept makes us so uncomfortable that we felt opening

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the debate to the wider community was important. In our opinion, these decisions must be agreed at Health Board level and with clear agreement of the ethical committee, which we not only have, but have been actively supported by them for raising the topic.

was discussed in the original paper but for clarity, this has been ‘truly’ reduced by a 31% absence rate across theatre staff (sickness, shielding, etc.). Staffing case mix shows last week, we had only three MSK theatre staff available to work across a seven day, 24-hour rota.

significantly insufficient capacity. Even before COVID-19, on a weekly basis, elective lists were cancelled in order to meet our trauma demand. This is despite regular requests over the past decade to the Executive Board to improve trauma capacity. Considering all of these factors, it should be easy to see how any hospital can quickly be reduced to breaking point.

The suggestion that Andrew Goodall’s statement that “Urgent and Emergency services for both physical and mental illness are still open and accessible” in Wales needs to be openly and critically discussed. The statement from Lewis et al. that “A&E attendances are down 60%, Health Boards have 49% critical care bed vacancy and staff sickness is only 9.2%”, pays no respect to the fact that individual Health Boards have varying metrics.

Maybe more importantly, despite the fact that critical care bed capacity has not been breached, theatre capacity has been ‘artificially’ reduced further by the removal of staff to cover critical care and other surge areas. In total, Morriston currently has only 46% of normal theatre staff available to work, and in the theatre environment where all patients are treated as presumed COVID-19 positive there is an increased number of staff required per theatre (up to 21 per shift, per theatre, if using a 3 zone model). We must also at this stage include the fact that as a Health Board, even before the COVID-19 pandemic, we have been running a trauma service at

The second ethical dilemma is therefore, the national decision and LHB interpretation of this, to put the care of potential COVID-19 patients (the size, timing and severity of the peak unknown), ahead of the care of acute patients currently in the hospital. This of course is outside the control of the Orthopaedic department, but we can assure you that we have raised this consistently over the past four weeks with the Executive Board and have yet to receive a satisfactory response.

“Despite the fact that critical care bed capacity has not been breached, theatre capacity has been ‘artificially’ reduced further by the removal of staff to cover critical care and other surge areas.”

In Swansea Bay UHB demand has certainly not reduced, we have admitted 58 Proximal Femoral Fractures in the last 24 days. Theatre capacity

If we wish to look outside of the ‘orthopaedic box’ we must also be cognisant of the fact that even as capacity increases, we must balance the care of our patients with those of other specialities. Currently in SBUHB we have a list of 143 ‘time critical’ cases (mainly cancer) that are not even being put into the daily discussion for theatre access. The recent publication by Prachand et al. in the Journal of the >>

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American College of Surgeons1 eloquently discusses this dilemma and interestingly the authors developed a scoring system to try and enable efficient management of what they term “medically-necessary, time sensitive procedures” during the COVID-19 pandemic. In response to the second question “Is the SHiFT scoring system supported by the established literature?”

equate to higher mortality rates and can therefore be used ‘fairly’. In no way do we suggest that our SHiFT score is validated but the alternative of subjective decision making is certainly no more appropriate and we suggest much less so. We are happy to discuss the details of the protocol, including changes such as removing the option of treating patients outside of hospital. However, we must suggest that again you all consider what would happen if your hospital truly had NO beds left, do you have a plan? If so, share it, reconsider it daily and be open to criticism, that in our view is the whole purpose of the Transient Journal.

“The Royal College of Surgeons described a potential pandemic situation when facilities and staff are stretched “beyond the edge”. Inevitably should this occur, this will result in a compromise to all levels of care. In such a situation the SHiFT triage system may present valuable prognostic information. We have not reached this stage.”

This raises the question of how you may wish to stratify patients. Ethical dogma agrees that a principle of fairness must be applied (treating like patients alike). By using objective scores that have been proven to relate to mortality, we have attempted to exclude the argument that the characteristics are irrelevant. For example, age cannot be used as a discriminator without evidenced reason. The NHFS clearly provides evidence that increasing age and male sex

We also in no way want to suggest that the small literature review included should be used to justify conservative treatment of proximal femoral fractures. The evidence as correctly discussed by Lewis et al. is in some

cases many decades old and provides no basis to suggest that non-operative treatment is a good thing. We accept that non-operative treatment will lead to poorer morbidity and mortality for this group. However, please remember our initial premise is that this is only to be used at the extreme lack of capacity where surgery must be rationed. Using the conclusion of Lewis et al., “The Royal College of Surgeons described a potential pandemic situation when facilities and staff are stretched “beyond the edge”. Inevitably should this occur, this will result in a compromise to all levels of care. In such a situation the SHiFT triage system may present valuable prognostic information. We have not reached this stage.” Four weeks ago, the NHS England specialty response ‘Clinical guide for the management of trauma and orthopaedic patients during the coronavirus pandemic’ quoted Dr Daniele Macchine, Bergamo, Italy, 9 March 2020, “…and there are no more surgeons, urologists, orthopaedists, we are only doctors who suddenly become part of a single team to face this tsunami that has overwhelmed us…”2. We now feel hopeful that this will not be the case in the UK but when our paper was written we appeared to be faced with a local ‘Perfect Storm’ and hoped that sharing our thinking and ethical dilemmas would spark debate and make others consider their own plan. This certainly appears to be the case. n

References 1. Prachand VN, Milner R, Angelos P, Posner MC, Fung JJ, Agrawal N, et al. MedicallyNecessary, TimeSensitive Procedures: A Scoring System to Ethically and Efficiently Manage Resource Scarcity and Provider Risk During the COVID-19 Pandemic. J Am Coll Surg. 2020. [Epub ahead of print]. 2. NHS England, (2020). Clinical guide for the management of trauma and orthopaedic patients during the coronavirus pandemic. Available at: https:// www.england.nhs. uk/coronavirus/ wp-content/uploads/ sites/52/2020/03/ C0274-Specialty-guideOrthopaedic-traumav2-14-April.pdf.

In Memoriam

John Seddon Hopkins 4th March 1930 – 22nd November 2019

ohn Seddon Hopkins was born in Hamilton New Zealand in 1930. His father was a General Surgeon in practice in Hoki-Tikka. Following the sudden death of his father a year after his birth, John’s mother returned to Yorkshire with him. He attended Huddersfield Grammar School and later Epsom College. At both schools he excelled academically and in all sports, particularly boxing. At Epsom College he became the Surrey County Junior Boxing Champion. He won a scholarship to study Medicine at Barts, where he later won the anatomy prize. After house jobs at Barts he was called for National Service where he became a Medical Officer in the Queen’s Own Cameron Highlanders. Most of his service was spent in Korea. After obtaining his FRCS in 1960 and deciding on a career in Orthopaedics, he worked at the Robert Jones and Agnes Hunt Orthopaedic Hospital in Oswestry. During this period he worked under the tutelage of Sir Reginald Watson Jones and Sir John Charnley. He later moved to the Woodlands Orthopaedic Hospital in Birmingham and subsequently became Senior Registrar at Leeds General Infirmary. In 1968 he was appointed Consultant at Harlow Wood Orthopaedic Hospital and Mansfield General Hospital. As a Consultant at Harlow Wood he developed a special interest in Bone Tumour Surgery and treatment. He was a dedicated surgeon and well respected colleague throughout his career.

Away from work John was a devoted family man, and after retirement moved to Buckinghamshire to be closer to his children and grandchildren. He loved to garden, visit places of historical interest and travel; returning on several occasions to New Zealand. He is survived by his wife of 59 years, Carmel, and his three daughters and two sons. n

Anthony John Hall

27th February 1938 – 17th February 2020

nthony ‘Tony’ Hall was born in Hull and educated at Harrogate Grammar School. He qualified in medicine at University College London in 1962. Having passed his FRCS in 1968, he moved to the Royal National Orthopaedic Hospital in Stanmore as Orthopaedic Registrar and then Senior Registrar between 1968 and 1972. In 1972 he was appointed Orthopaedic Fellow at Toronto General Hospital in Canada. He returned to the RNOH before taking up a consultant post at Charing Cross Hospital in 1973. In 1990 he moved to the new Chelsea and Westminster Hospital where he stayed until he retired from NHS practice in 2001. He held the position of Honorary Orthopaedic Surgeon at the Royal Marsden Hospital between 1985 and 2001 and was a Medical Member of the Pensions Appeal Tribunal from 1996. Alongside his clinical work he had a busy career in medical education. He was appointed Postgraduate Sub-Dean at Charing Cross Hospital Medical School in 1978 and was honoured with the role of President of Medical School Rugby Club. He was the Regional Advisor in Orthopaedics for NW Thames from 1987, becoming Chairman of the North Thames Regional Training Committee in 1992. He was appointed to the Court of Examiners of the Royal College of Surgeons in 1985 and as an Examiner for Final & Master’s Degrees for the University of London in 1993. He became Member of Council of the British Orthopaedic Association in 1989 and BOA Representative to the Specialty Advisory Board from 1991 - 1993. He was Chairman of the organising committee of the BOA Meeting at Wembley in 1992.

He was also a passionate member of SICOT (Société Internationale de Chirurgie Orthopédique et de Traumatologie) connecting him with many colleagues and friends across the world. He was a member of the organising committee of the SICOT Congress London 1984, a National Delegate between 1990 and 1993 and General Secretary between 1993 and 2002. He was Deputy Editor of International Orthopaedics from 1987 - 2013, serving alongside this role on the Editorial Board. He continued to work as Chief Examiner for SICOT from 2002 until recently. He died peacefully at home in Hampshire on 17th February aged 81. He is survived by his wife Avis; his three children; Simon, Charles and Julia and six grandchildren. n

Journal of Trauma & Orthopaedics - Vol 8 / Iss 2

Articles inside

In Memoriam: John Seddon Hopkins, Anthony John Hall

A response to the letter by Lewis et al. from the authors of: COVID-19 causes a SHiFT in the sands for proximal femoral fracture management?

COVID-19 causes a SHiFT in the sands for proximal femoral fracture management?

A letter in response to: COVID-19 causes a SHiFT in the sands for proximal femoral fracture management? A plea for caution

From the Executive Editor

Training in orthopaedics: The show must go on

From the President: Working together – the way forward

10 Latest News

Non-accidental injury in children in the time of COVID-19 pandemic

Coronavirus (COVID-19): My experience of testing positive