Self-harm is a significant and increasing healthcare problem that is often met with prejudice and stigma, even by healthcare staff (Kilroy-Findley, 2015; MIND, 2016; NICE, 2022; Saunders et al., 2012). It is exceedingly common, with approximately one in ten adolescents reported as having self-harmed (NICE, 2022). Those who frequently self-harm require the input of hand surgery services, usually due to lacerations from self-cutting and foreign body soft tissue insertion (FBSTI) (Rogers et al., 2009). Of those who self-harm, over 50% will repeatedly do so in the future. Self-harm also remains the strongest risk factor for a subsequent suicide attempt (Hawton et al., 2012; Madge et al., 2008) with a 19-fold increased risk of suicide and a 3.6 fold increased risk in all-cause mortality (Kapur et al., 2015). This is a significant burden of disease, estimated to cost health services from £200 up to £10,000 per patient, per year (Hunt, 2017; Rogers et al., 2009). The management of patients who self-harm requires collaboration between the psychiatric and surgical services. Despite the integral role of the hand surgery team in the management of such patients, self-harm receives very little attention in the surgical literature and there are no clear guidelines nor consensus on the surgical management of these patients. This article aims to better equip hand surgeons when managing patients who have selfharmed by summarizing the available evidence and guidelines on both the nature of self-harm and its management.

Introduction-Nonfreezing cold injury (NFCI) occurs when tissues are subjected to prolonged cooling that causes tissue damage, but not freezing. Long-term effects include cold intolerance, with allodynia, pain, or numbness of the affected limb. Those who participate in outdoor paddlesports are at particular risk.Methods-This is an epidemiological study that aimed to determine the risk factors for paddlesport athletes developing NFCI and chronic cold intolerance in their hands. Secondary outcomes were to correlate cumulative cold exposure with the development of cold intolerance and to identify risk factors for developing NFCI or cold intolerance. Six hundred nine athletes responded to a survey distributed by their national governing body obtaining demographic and activity details, symptoms of NFCI, and a cold intolerance severity score (CISS).Results-Twenty-three percent reported symptoms consistent with acute NFCI. The median CISS was 31 y (interquartile range 25-43), and 15% had a pathological CISS defined as >50. Females and individuals with Raynaud's phenomenon or migraines had a significantly higher CISS (P<0.05). Regression analysis found that females, smokers, and those with Raynaud's phenomenon or a previous nerve injury had a significantly higher risk of developing pathological cold intolerance (CISS >50). There was no correlation between cumulative cold exposure and CISS. Conclusions-A large proportion of paddlesport athletes undertaking activity in cold conditions have a pathological CISS or episodes consistent with NFCI. Cumulative cold exposure was not associated with a pathologically high CISS. The risk factors were female sex, smokers, and those suffering from either Raynaud's phenomenon or nerve injury.

Introduction Displaced distal radius fractures often require manipulation under anaesthesia. Many anaesthetic techniques are described, with the two most commonly used being Bier's block (BB) and haematoma block (HB). Despite national guidance preferring a BB, an HB is often performed instead. This study aims to compare the analgesic properties of a BB with those of an HB when manipulating distal radius fractures. Methods This is an observational cohort study comparing the management of displaced distal radius fractures requiring reduction across two National Health Service trusts. Patients aged over 18 with isolated, displaced distal radius fractures were recruited. Patient demographics, AO fracture classification and grade of clinician performing the procedure were recorded. A numeric rating scale (NRS) pain score was obtained for each patient after manipulation. The quality of reduction was judged against standardised anatomical parameters. Results Some 200 patients were recruited (100 HB, 100 BB). There were no differences in age (BB: median 66.5 years, interquartile range [IQR] 55-74; HB: median 67 years, IQR 55-74; p = 0.79) or fracture characteristics (p = 0.29) between cohorts. Patients undergoing BB had significantly lower pain scores with a lower IQR than those undergoing HB (p < 0.005). Patients undergoing BB manipulation were more likely to have the fracture reduced and normal anatomy restored (p < 0.005). BBs were performed mainly by Foundation Year 2 junior doctors, whereas HB manipulations were performed by a range of clinicians from emergency nurse practitioners to consultants. Conclusions BB provides better analgesia than an HB. This can be performed successfully and reliably by Senior House Officer-level junior doctors.

INTRODUCTION:In the surveillance of children with cerebral palsy, the measurement of migration percentage is used to identify children at risk of hip dislocation. Early identification of children at risk facilitates early intervention with less invasive surgical procedures to prevent further deterioration. The aim of this study is to evaluate the safety of the measurements of migration percentage for surveillance in cerebral palsy by extended-role radiographers by evaluating the reliability and validity of measurements performed by these professionals. METHODS:A sample of thirty pelvic x-rays were selected from the local cerebral palsy database. A range of hip displacement was selected including some challenging borderline x-rays. All ten extended-role radiographers completed measurements using TraumaCAD which were repeated at a minimum of 4 weeks. Inter-rater and intra-rater reliability was calculated using intraclass correlation coefficients. The accuracy and safety of the system was evaluated by converting measurements into referral categories (red, amber or green) and cohen's kappa was calculated when categories were compared to measurements to orthopaedic surgeon RESULTS: The inter-rater reliability between radiographers was 0.938 (95% CI 0.914-0.991). The intra-rater reliability was 0.941 (95% CI 0.931-0.949). The percentage agreement was 94.8% for green, 93.8% for amber and 98.2% for red hips. The weighted kappa value was 0.923 (95% CI 0.889-0.957). CONCLUSION:The reliability and accuracy of radiographer measurement of migration percentage is excellent. It is safe for radiographers to calculate the migration percentage using semi-automated software for the surveillance of children with cerebral palsy. IMPLICATIONS FOR PRACTICE:We recommend the measurement of migration percentage may be performed by extended-role radiographers to deliver accurate and reliable measurements for use in cerebral palsy surveillance.

Objectives: To determine if the introduction of the best practice tariff (BPT) has improved survival of the elderly hip fracture population, or if achieving BPT results in improved survival for an individual.Setting: A single university-affiliated teaching hospital.Participants: 2541 patients aged over 60 admitted with a neck of femur fracture between 2008 and 2010 and from 2012 to 2014 were included, to create two cohorts of patients, before and after the introduction of BPT. The post-BPT cohort was divided into two groups, those who achieved the criteria and those who did not.Primary and secondary outcome measures: Primary outcomes of interest were differences in mortality across cohorts. Secondary analysis was performed to identify associations between individual BPT criteria and mortality.Results: The introduction of BPT did not significantly alter overall 30-mortality in the hip fracture population (8.3% pre-BPT vs 10.0% post-BPT; p=0.128). Neither was there a significant reduction in length of stay (15 days (IQR 9-21) pre-BPT vs 14 days (IQR 11-22); p=0.236). However, the introduction of BPT was associated with a reduction in the time from admission to theatre (median 44 hours pre-BPT (IQR 24-44) vs 23 hours post-BPT (IQR 17-30); p<0.005). 30-day mortality in those who achieved BPT was significantly lower (6.0% vs 21.0% in those who did not achieve-BPT; p<0.005). There was a survival benefit at 1 year for those who achieved BPT (28.6% vs 42.0% did not achieve-BPT; p<0.005). Multivariate logistic regression revealed that of the BPT criteria, AMT monitoring and expedited surgery were the only BPT criteria that significantly influenced survival.Conclusions: The introduction of the BPT has not led to a demonstrable improvement in outcomes at organisational level, though other factors may have confounded any benefits. However, patients where BPT criteria are met appear to have improved outcomes.

Background: Clear communication among health-care teams is paramount for safe patient care and effective handover. Advances in information technology have led to an increased use of electronic systems within modern health care. This quality improvement project introduced an electronic patient handover system that was intended to improve the accuracy of patient handover lists and be readily available to all members of the health-care team. Methods: A quality improvement project was undertaken to assess the effect of introducing an electronic patient handover system on maintenance workload and list accuracy. Results: List errors were common before the introduction of the electronic patient handover system, commonly patient location or a patient being incorrectly omitted from the list. These errors decreased significantly after the introduction of the electronic system (P<0.005 and 0.04 respectively). The workload associated with its maintenance also decreased (P<0.005) because many data fields were pre-populated by the software. This resulted in fewer instances of patients being missed on ward rounds (P<0.04). Conclusions: Through modifying existing information technology infrastructure, a centrally maintained, widely accessible electronic handover system was introduced. This reduced the workload associated with maintaining handover lists and the rate of errors.

Aims: Surgical resection is often the only curative treatment for oesophageal cancer. The aim of this retrospective cohort study was to analyse outcomes following oesophageal resection in patients aged 75 years and older and the impact of an Enhanced Recovery after Surgery (ERAS) program in this cohort.Methods: Patients aged over 75 years undergoing oesophagectomy between 2003 and 2013 were identified from a single centre using an electronic database. Data on pre-operative comorbidity, tumour stage and length of hospital stay (LOS) were collected. Complications were classified according to the Clavien-Dindo system. Thirty day, 1- and 5-year mortality rates were calculated.Results: 147 patients were identified with a median age of 78.5 (IQR 76.7-80.9). 33% (n = 44) had a grade 3 complication or higher. Median LOS in hospital was 16 days (IQR 13.0-22.0). Thirty-day mortality was 3.4%, 1-year and 5-year survival was 65% and 21% respectively. 45% of patients were enrolled into an Enhanced Recovery After Surgery program and they demonstrated a significantly reduced length of stay from 18 to 14 days (p = 0.005) and 30-day mortality from 6.2% to 0% (p = 0.04) compared to the time period before the program.Conclusion: Long-term survival is achievable in patients aged over 75 years. (C) 2016 Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).