This chapter describes common orthopaedic conditions with heavy emphasis on the relevant clinical details that should be elucidated on history and examination. With a firm grasp of the principles of clinical orthopaedic assessment, a differential diagnosis can be formulated and appropriate investigations performed subsequently.

FRACTURES

Fractures can be divided into the following types:

The audit of medical practice is neither a new concept nor a new activity. All medical practitioners have examined the effects of their treatment and have assessed outcome for centuries. The major advances in medical practice, particularly during the twentieth century, would not have occurred without observing and assessing the effects of treatment regimes. The main effect of the changes indicated in the HM Government White Paper ‘Working for Patients’ and subsequently the National Health Service and Community Care Act (1990) and the directives from the various Royal Colleges has been to emphasise the need for audit activity and to introduce a more formal basis to audit. Audit has also been linked to the need for the cost-effective use of resources.

The purposes of this book are firstly to describe the philosophy of audit in medical practice; secondly to establish the types of information required by the different groups interested in audit; thirdly to outline the ways in which audit activity is being undertaken in various specialties; and fourthly to suggest a coherent pattern for audit and make recommendations for the acquisition and storage of large volumes of information.

Definitions

The general public concept of audit is the annual review of the ‘books’ of a business.

Introduction

Why should clinicians be involved in clinical audit? Amongst some clinicians there is open hostility to the concept of formal audit of medical practice. Further, with the introduction of the National Health Service (NHS) reforms and the devolvement of financial control to the level of consultant clinicians the resistance to particularly the resource aspects of audit is even more apparent.

The managers want waiting lists reduced, waiting times in clinics to be at a minimum and a cost-effective service provided, but they also expect the clinicians to be directly involved in the management structure and to provide much of the managerial information. The ‘big brother’ concept plays a significant role in the fears of the imposition of formal audit. Cries of loss of clinical freedom abound as clinicians are asked to justify their actions to the purse holders.

Before the answer posed in the title of this chapter can be approached it is necessary to define what has been the role of audit to date. The Working for Patients White Paper and Royal College directives on clinical audit have changed the perception of clinical audit and along with this change in perception the fears have grown. Audit of all aspects of medical practice has been around and undertaken for many years.

Introduction

As with all other specialties, orthopaedic and trauma surgeons have been undertaking ‘audit’ in its broadest sense for decades. However, in terms of formalised, structured audit orthopaedics is well behind other specialties. It is self-evident that for any specialty to develop some form of systematic review has to be undertaken. Orthopaedic surgery differs from many specialties in that the true effect of any treatment/management regime and any complications that may arise may not be apparent for many years. Audit in orthopaedics must, therefore, be looked at in two levels – (i) short-term effects and (ii) the eventual outcome whenever that occurs. Any guidelines to implement audit in the specialty have to include review at both levels. Further, in order to be realistic about audit in orthopaedics resource management cannot be ignored. Many orthopaedic operations involve the use of expensive implants. There is a tendency to use the ‘flavour of the month’, which may also be the most costly available at the time. Orthopaedic surgeons must, therefore, act responsibly in using new implants and be able, and willing, to justify their use when challenged.

Like many other specialties orthopaedics has undergone dramatic and irreversible changes in the last 20 years or so.