Introduction: The United Kingdom (UK) is likely to see an increase in cycling due to government cycling promotion initiatives. With this, it is becoming increasingly important to inform clinicians about the injuries sustained by cyclists, although literature on this topic is scarce. This study aims to address this by characterising orthopedic fractures (of the limbs or pelvis) sustained by cyclists admitted to the major trauma centre in Cambridge,the region with the highest cycling rates in the UK. Methods: A retrospective review of all patients sustaining cycling-related orthopaedic fractures admitted to our centre between January 2012 - December 2020 was performed. Our institution's electronic record system was used to collect data including: age, gender, injury mechanism, fractures sustained, treatment,, Glasgow Coma Scale score at scene and Injury Severity Score. Results: Of the 737 patients admitted due to cycling related injuries, 292 patients (225 males, 67 females) with a median age of 50.5 years sustained a total of 510 orthopaedic fractures. Fractures were significantly more common in those aged over 50 (P<0.0001). Upper limb fractures accounted for 41.4% of all fractures, lower limb 33.9% and pelvis 24.7%. Accidents involving a motorised vehicle were more likely to result in a fracture than those involving no motorised vehicle. Lower limb fractures and motorised accident fractures were significantly more likely to require surgery (P<0.001). Discussion: This study provides a unique characterisation of orthopedic fractures sustained by cyclists in the UK. Such information is important to both treating clinicians and policy makers developing accident prevention interventions.

Objective: Determine the frequency, characteristics and use of resources related to electric scooter (e-scooter) injuries in the emergency department (ED) of a major metropolitan area hospital. Methods: We performed a retrospective review of all ED presentations related to e-scooter injuries at a level-I trauma center between May 2017 to February 2020. We identified ED presentation data, injury-related data, patients’ clinical course after evaluation, diagnosis of injuries, surgical procedures, and ED readmissions. Results: A total of 3,331 patients with e-scooter injuries over a 34-months period presented to the ED. There was a 6-fold increase in e-scooter related injuries presenting to the ED from an average of 26.9 injuries per month to 152.6 injuries per month before and after the introduction of shared e-scooter services in August 2018. The average injury rate during weekdays was 3.27 per day with majority of injuries occurring in the afternoon. The most common mechanism of injury was rider fall (79.1%). A total of 2637 orthopedic injuries were documented, of them 599 (22.7%) were fractures. A total of 296 (8.9%) patients were hospitalized following the initial ED encounter and 462 surgeries were performed within seven days of ED arrival. Conclusion: The introduction of the shared e-scooter services is associated with a dramatic increase in e-scooter injuries presenting to the ED. E-scooter use carries considerable injury risks with underestimation of high-energy trauma and misunderstood mechanism of injures. These injuries that challenge the health care system with a considerable impact both on the ED and surgical departments.

Introduction: Electric scooters are being used throughout the world as a new means of transport. E-scooter shared schemes have recently been piloted in the United Kingdom, however there is no published data on orthopaedic injury and user behaviour patterns in the UK. We aim to identify the patterns and severity of orthopaedic injuries related to the use of e-scooters in the capital.
Methods: We performed a retrospective review of all orthopaedic referrals relating to e-scooter use from March 1 to November 30, 2020 at three hospitals, including one major trauma centre in central London. Data including patient demographics, mechanism of injury, diagnosis, and treatment were collected.
Results: One hundred and five orthopaedic injuries were identified in 83 patients. The median age was 32 years and 83% were male. 79 (95.2%) patients were riders, 4 pedestrians. All e-scooters were privately-owned. There were 93 fractures (88.6%) including 12 (13.5%) open fractures. 52 (56.0%) were upper limb fractures and 39 (41.9%) lower limb. 25 patients (30.1%) required an operation and 29 patients (34.9%) required hospital admission. Helmet use was 34.1%. The most common place of injury was the road (65.1%) followed by pavement (32.9%).
Conclusion: This is the first report of e-scooter related orthopaedic injuries in the UK. E-scooter injuries can involve high energy trauma requiring operative intervention. As e-scooters become more ubiquitous, the number of orthopaedic injuries is likely to increase. Serious consideration should be taken in the drafting of safety regulations to ensure appropriate injury prevention mechanisms are in place.

Introduction: The popularity of electric scooters (e-scooters) and the shared e-scooter services as new means of transportation worldwide led to high numbers of injuries requiring emergency department (ED) visits. Private and rental e-scooters have different sizes and capabilities, offering several possible riding positions. While the rising use of e-scooters and their associated injuries have been reported, little is known about the influence of riding position on injury characteristics. The purpose of this study was to characterize e-scooter riding positions and their related injuries.
Materials and Methods: E-scooters related ED admissions were retrospectively collected between June 2020 and October 2020, in a level-I trauma center. Demographics, ED presentation data, injury information, e-scooter design, and clinical course were collected and compared according to e-scooter riding position ("side-by-side" vs. "foot behind foot"). Results: During the study period, 157 patients were admitted to the ED with e-scooter related injuries. Most of the injuries occurred on the road (61.8%), and the most common mechanism of injury was rider-fall (77.1%). Orthopedic fractures were the most common injuries (n=77, 49.0%). "Foot behind foot" group had significantly higher fracture rate compared to "side-by-side" group (60.4% vs. 37.2%, respectively; p=0.03).
Conclusions: Orthopedic fracture rates were significantly higher in the more commonly used “foot behind foot" e-scooter riding position. This study findings suggest that the current common e-scooter narrow-based design is considerably more dangerous, calling for further research to introduce safer e-scooter designs and update recommendations for safer riding positions.

Purpose: Alcohol has been associated with 10-35% trauma admissions and 40% trauma-related deaths globally. In response to the Covid-19 pandemic, the United Kingdom (UK) entered a state of ‘lockdown’ on 23rd March 2020. Restrictions were most significantly eased on 1st June 2020, when shops and schools re-opened. The purpose of this study was to quantify the effect of lockdown on alcohol-related trauma admissions.

Methods: All adult patients admitted as ‘trauma calls’ to a London Major Trauma Center (MTC) during April 2018 and April 2019 (pre-lockdown; N=316), and 1st April – 31st May 2020 (lockdown; N=191) had electronic patient records (EPRs) analysed retrospectively. Patients’ blood alcohol level and records of intoxication were used to identify alcohol-related trauma. Trauma admissions from pre- and post-lockdown cohorts were compared using multiple regression analyses.

Results: Alcohol-related trauma was present in a significantly higher proportion of adult trauma calls during lockdown (lockdown 60/191 (31.4%), versus pre-lockdown 62/316 (19.6%); (Odds Ratio (OR) 0.83, 95% CI 0.38 to 1.28, p<0.001). Lockdown was also associated with increased weekend admissions of trauma (lockdown 125/191 weekend (65.5%) vs pre-lockdown 179/316 (56.7%); OR -0.40, 95% CI -0.79 to -0.02, p=0.041). No significant difference existed in the age, gender, or mechanism between pre-lockdown and lockdown cohorts (p>0.05).

Conclusions: UK lockdown was independently associated with an increased proportion of alcohol-related trauma. Trauma admissions were increased during the weekend when staffing levels are reduced. With the possibility of further outbreaks of Covid-19, the long-term repercussions of dangerous alcohol-related behaviour to public health must be addressed.

Introduction: The Covid-19 pandemic has adversely affected healthcare systems across the world. Many countries, even those with well-established healthcare systems, are buckling under the weight of this new disease. Most specialties ceased elective procedures, focusing resources on the sickest patients, with staff being redeployed to help with Covid-19 patients. In Orthopaedics, however, trauma still forms a significant part of the workload, even in a pandemic. We aim to quantify the change in orthopaedic trauma workload in a Level 1 and Level 2 trauma centres during a global pandemic-related lockdown, and to ascertain levels of staffing required. Methods: We collected data from two hospitals in the UK, Level 1 and Level 2 trauma centres, relating to number of accident and emergency referrals, inpatient admissions, operations and fracture clinic attendances for six weeks during the lockdown from 23rd March to 3rd May 2020. We compared this to data from the same six-week period in 2019. Results: The overall orthopaedic trauma workload, consisting of operations, referrals, admissions and fracture clinic appointments, reduced by an average of 54.2% during the lockdown in 2020, compared to the same period in 2019. Conclusion: This shows that, even in a pandemic lockdown, there is a significant orthopaedic trauma workload and staff resources must be correspondingly allocated. A proportion of orthopaedic staff will need to be ring-fenced from redeployment in order to provide sickness cover, as well as a safe and appropriately managed service.

Introduction: Frailty is a health state in which body systems gradually lose their in-built reserves, linked to greater hospitalisation, morbidity, and mortality. British Orthopaedic Association Standards for Trauma (BOAST) guidelines currently state that trauma patients with a Clinical Frailty Score (CFS) of 5 or more should receive multidisciplinary care. A 2017 Trauma audit and research network (TARN) report identified that further research was needed to determine the effect of frailty on outcomes in trauma patients. This retrospective cohort study sought to investigate the effect of frailty on mortality and length of stay in hospitalised patients with fragility fractures. Methods: All patients aged over 60, admitted to a large district general hospital over 1 year, with any fragility fracture were included and notes were reviewed retrospectively. Age, injury, length of stay, and mortality were recorded. A Clinical Frailty Score (CFS) was assigned retrospectively using the Rockwood Clinical Frailty Scale. Results: 886 patients were reviewed (male:female 266:620, mean age 82.75). Increases in CFS independently increased odds of death by 55% at 30 days (OR 1.545, 95% CI 1.272-1.876, p<0.001) and by 54% at 1 year (OR 1.538, 95% CI 1.348-1.754, p<0.001). 826/886 (93.2%). Conclusion: CFS independently predicts adverse outcome in hospitalised trauma patients. CFS should be used routinely to identify patients at risk of poorer outcomes and may assist in allocation of limited orthogeriatric resources and supporting BOAST guidelines. Future research should investigate how additional resources affect outcomes for patients at each level of CFS.

Background: While traumatic brain injury (TBI) leads to excessive bone formation and enhanced fracture healing, the effect of brain insult in cerebral fat embolism syndrome (CFES), on fracture healing has not been analyzed. The aim of this study was to compare the pattern of fracture healing in long bones amongst patients with CFES, TBI and patients without either of these. Patients and methods: Amongst the 34 patients diagnosed to have CFES, 19 patients (Group-1) with 26 fractures (14 tibia,12 femur) were analyzed. The volume of callus formed was measured using callus index (CI) and time taken for bony union were compared with that of TBI (Group-2) and a control group (Group-3) which comprised of a simple fracture of tibia or femur treated with ILN. Results: The mean value of CI amongst femur fractures in CFES group was 1.78±0.3 and comparable to that of 1.73±0.3 in TBI group, however was significantly higher than control group (1.38±0.3) (p-0.0029). In tibia fractures, the mean CI of 1.41±0.2 in CFES group was similar to 1.34±0.2 in TBI group but was again significantly higher than the control group 1.16±0.1(p-0.008). However, the mean fracture union time of femur (17.33±5 weeks) and Tibia (16±5 weeks) in CFES group were not higher than that of control group. Conclusion: Fracture healing in CFES was found to have an exuberant callus formation similar to that of TBI. In-depth analysis of biological factors and proteins responsible for the enhanced osteogenic potential in these groups may pave way for novel regenerative-therapies.

Background: The high prevalence of hypovitaminosis D among trauma patients have been related to conflicting reports on risk of fractures, falls, non-union and poor clinical outcomes after surgery. There is limited evidence that ties up Vitamin D levels with fracture severity with specific fractures. The primary objective of this study is to determine the association of pre-operative level of Vitamin D and the fracture severity among adult trauma patients. No previous study used the AO classification to stratify fracture severity and relate this to vitamin D levels at time of injury.

Methods: All patients operatively treated for extremity fractures with pre-operative Vitamin D levels were reviewed. AO classification was assigned to all fractures present at injury. Demographics, presence of osteoporosis, mechanism of injury and comorbidities were obtained for each patient. Follow-up clinical, radiographic data and fracture union were all recorded.

Results: Ninety-six patients with 104 surgically-treated extremity fractures were included. Patients presenting with more severe fractures were associated with lower levels of Vitamin D and higher prevalence of hypovitaminosis D compared to patients with less severe fractures. There was a strong, positive correlation between Hypovitaminosis D and increasing fracture severity, which was statistically significant. This association remains present in a sub-group analysis of patients without osteoporosis, and in another sub-group of patients who sustained low-mechanism injuries. Union rate among our subjects is 97%.

Conclusion: Pre-operative vitamin D level is associated with the severity of fracture as described in the AO classification sustained at the time of injury.

Background: We examined the differences between Suprapatellar and Infrapatellar nailing of tibia fractures regarding pain, range of motion of the knee and alignment and union of the tibia.

Methods: The study population was identified from our database and collected prospectively during routine post-surgery examinations. The study population was divided into 2 groups: those who had infrapatellar point of entry (n=44) and those who had a suprapatellar approach (n=41) in tibial nailing surgery. We have compared the surgery outcomes between the two groups by examining the post-operative pain levels (using VAS Score), knee function (using Lysholm Knee Score) and alignment and union of the tibia (determined by x-ray).

Results: 85 patients were included, of which 44 (51.7%) patients were part of the infrapatellar group. When analyzing patients in both groups, they were of the same age (42.45±18.71 vs 36.39±15.53, p-value 0.10), mostly males (79.5% vs 68.3%, p-value 0.24) and had the same diabetes mellitus incidence (13.6% vs 4.9%, p-value 0.27). We found no significant difference between the infrapatellar and suprapatellar approach in post-operation pain levels (RR -0.529, 95%CI [-1.973;0.914]), range of motion in the end (145 (130-145) vs 145 (130-145) degree, p-value 0.75), post-operation knee function (RR -1.444, [-8.858;5.970], p-value 0.70) and in the degree of alignment and union of the tibia (100% vs 100%, 93.2% vs 95.1% respectively).

Conclusion: We found no difference between the infrapatellar and suprapatellar approach for tibial shaft fracture repair regarding post-surgical pain levels, knee function and union and alignment .

The treatment of periprosthetic fractures represents a challenge, not only due to their technical complexity but also their high mortality (11-44.8%). As the population ages and more frequent arthroplasties are performed, these fractures will become more and more frequent. The aim of this study was to evaluate the clinical results and to identify predictors of morbi and mortality. The clinical and radiographic records of all patients who underwent surgery for periprosthetic hip and knee fracture were retrospectively evaluated. 55 patients were identified, (31hips and 24 knee). 56% of patients were ASA 3, with average age of 78 years. The drop in mean hemoglobin was 3.2 g/dL, 73% of which required transfusion. 42 osteosyntheses were performed with plaque (20 hip, 22 knee), 2 with endomedullary nail (knee) and 11 revisions of hip arthroplasty. The average time to surgery was 3 days and the average hospital stay was 26 days. 61% of patients had previously autonomous gait, 30% supported walking and 7% were bedridden. After one year, 40% had not recovered the ability to walk. There were 15% re-interventions. 30 days Mortality was 3.6% and one year mortality was 15%. 30 days Mortality was associated with ASA (p = 0.015). One year mortality was associated with age (p = 0.004), ASA (p = 0.004) and recovery of walking ability at 6 months (p = 0.005). No other associations were found. Understanding these and other factors may help to improve the treatment of a condition whose prevalence will certainly continue to increase.