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Application of CHG-impregnated or control (Comfort Bath; Sage) cloths applied over entire body thrice weekly.
Recruits were monitored daily for SSTI. Baseline and serial nasal and/or axillary swabs were collected to assess S. aureus colonization.
Of 1,562 subjects enrolled, 781 (from 23 platoons) underwent CHG-impregnated cloth application and 781 (from 21 platoons) underwent control cloth application. The rate of compliance (defined as application of 50% or more of wipes) at 2 weeks was similar (CHG group, 63%; control group, 67%) and decreased over the 6-week period. The mean 6-week SSTI rate in the CHG-impregnated cloth group was 0.094, compared with 0.071 in the control group (analysis of variance model rate difference, 0.025 ± 0.016; P = .14). At baseline, 43% of subjects were colonized with methicillin-susceptible S. aureus (MSSA), and 2.1% were colonized with MRSA. The mean incidence of colonization with MSSA was 50% and 61% (P = .026) and with MRSA was 2.6% and 6.0% (P = .034) for the CHG-impregnated and control cloth groups, respectively.
CHG-impregnated cloths applied thrice weekly did not reduce rates of SSTI among recruits. S. aureus colonization rates increased in both groups but to a lesser extent in those assigned to the CHG-impregnated cloth Intervention. Antecedent S. aureus colonization was not a risk factor for SSTI. Additional studies are needed to identify effective measures for preventing SSTI among military recruits.
Diverse group of injuries – note metatarsal/Lisfranc section above.
Navicular fractures are divided into four types – dorsal lip (avulsion), tuberosity, body and stress fractures.
Cuboid injury is usually undisplaced fracture which responds well to hard-soled shoe orthoses. Beware of the ‘Nutcracker fracture’, a high energy abduction injury, crushing the cuboid, shortening the lateral column and potentially extruding the cuboid. This requires ORIF usually.
Cuneiform injury is rarely isolated and responds to POP immobilisation unless significantly displaced when ORIF is the normal treatment.
Most phalangeal fractures occur in the proximal phalanx of the fifth toe following indirect trauma – stubbing of the toe.
Metatarsophalangeal and interphalangeal dislocations should be reduced a soon as possible but rarely require surgery unless open injuries.
Pain, swelling and sometimes deformity.
Careful identification of the most tender area will be particularly beneficial when assessing the X-ray.
Foot compartment syndrome must be suspected in a painful swollen foot and tested for by passively stretching the muscles of the relevant compartment.
AP and lateral X-rays centred on the area of tenderness are essential.
Look for significant angulation, intra-articular steps and joint subluxation.
If there is doubt regarding fracture extent or joint congruity then CT scanning is extremely helpful.
ABCs, assess soft tissues, neurovascular status, reduce fractures/dislocations obviously threatening the skin and immobilise with backslab.
Admit, elevate and assess for compartment syndrome in the severely injured foot even without fractures.
General trauma principles apply such that joint congruity must be restored, either following joint dislocation or in intra-articular fractures.
Navicular body fractures usually require ORIF.
Nutcracker cuboid fractures are normally treated with ORIF and bone graft.
Previously known as congenital dislocation of the hip (CDH), but now recognised as a developmental failure of the acetabulum around the femoral head.
A dysplastic acetabulum is shallow and ‘vertical’ rather than concentrically covering the femoral head. This allows an increased degree of instability in the hip joint which, in extreme cases, presents as frank dislocation of the hip. However, this is a spectrum of disease and DDH often has a bearing on the aetiology of early adult hip OA.
Female : male ratio of 7:1. Left hip more commonly affected than right; bilateral in 20% cases.
The reported incidence of neonatal hip instability is 5–20/1000 live births, but following re-examination 6 weeks later, the incidence falls to 1–2/1000 infants.
Risk factors include family history (including maternal/sibling DDH, joint laxity and shallow acetabulae), breech presentation, oligohydramnios, other developmental anomalies, high levels of oestrogen, progesterone and relaxin in the last few weeks of pregnancy, and cultural post-natal factors (swaddling increases the risk, e.g. North American Indians, whereas encouraging legs to be widely abducted to allow sitting astride the back, as in southern Chinese and certain African peoples, decreases the risk of DDH).
Neonatal diagnosis is the gold standard. Look for decreased abduction in flexion, unequal gluteal and groin folds (only a ‘soft sign’ though) and an apparently short femur (Galleazzi test), but beware bilateral DDH.
Ortolani test – the dislocated or subluxed hip (out) is relocated (in flexion and abduction) by ‘lifting up’ with pressure on the greater trochanter.
Barlow's test looks for instability by pushing back (i.e. posterior) in the flexed hip.