DJ Moore; BMJ Case Report: 2012; Sequential bilateral femoral fractures

Sequential bilateral femoral fractures

BMJ 2012; 345 doi: (Published 14 November 2012)

Cite this as: BMJ 2012;345:e7361
  1. Seyed Ali Moeinoddini, foundation year 2 trainee, orthopaedic surgery1,
  2. Rajkumar James Parikh, consultant geriatrician1,
  3. Sarah Ruth Moore, specialist registrar, rheumatology and general (internal) medicine 2,
  4. David James Moore, consultant radiologist 3

A 78 year old woman presented to the emergency department with an off-ended, shortened, anteriorly deviated, long oblique fracture of the right femoral diaphysis. She had been experiencing thigh pain for several weeks before this acute presentation and analgesia had been prescribed.

She described feeling the bone “crack” as she turned around. There was no history of trauma. The fracture was surgically treated with an intramedullary nail.

Six months earlier she had sustained a similar fracture of the midshaft of her left femur. Again, there was no trauma and she described feeling the bone “crack” as she twisted slightly to go through her front door. She was unable to reach a telephone to call for help and spent some time on the ground before a passer by called an ambulance. After initial treatment with a Thomas splint, she was treated surgically with an intramedullary nail. After two weeks of rehabilitation she returned home to live independently and was able to go out with one stick to do her shopping.

Her medical history included osteoporosis and hypovitaminosis D. The diagnosis of osteoporosis was made after she sustained a vertebral crush fracture. She had been receiving bisphosphonates to prevent further fractures for nearly five years.


  • 1 Why are such fractures described as “atypical”?

  • 2 What underlying mechanism might explain such fractures?

  • 3 What are the main clinical and radiological features of atypical femoral fractures?

  • 4 How would you investigate her thigh pain?

Ralte, P, Grant, S, Withers, D, …Waseem, M

Intramedullary fixation of diaphyseal clavicle fractures using the Rockwood clavicle pin: a review of 68 cases

P Ralte,  S GrantD WithersR WaltonS MorapudiR BassiJ Fischer and M Waseembone_and_joint
Orthopaedic Proceedings: The Bone and Joint Journal 2012 –
Purpose Plating remains the most widely employed method for the fixation of displaced diaphyseal clavicle fractures. The purpose of this study was to assess the efficacy and outcomes of diaphyseal clavicle fractures treated with intramedullary fixation using the Rockwood clavicle pin.

Lucas, A; Continuing professional development, friend or foe?


Published in British Journal of Midwifery, Vol. 20, Iss. 8, 02 Aug 2012, pp 576 – 581

This article demonstrates processes used by managers to identify learning needs including the attainment of competencies, self assessment and appraisal. 

Adamson et al (1998) suggests that a career is not just about what one does for a living, but about what one has done in the past, does now and might do in the future. Sennett (1998) concurs, relating a career to a ladder to be climbed to reach a desire for status and fulfilment. It is also believed that the learning process should be prominent in career planning (Mumford, 1990)—indeed acquiring new skills has enabled me to develop into my current role as a ‘functional‘ manager (Charan et al, 2001).learning methods are reviewed as the author reflects on the importance of continuous professional development within her organisation.

My career pathway has changed from being purely clinical as a Labour Ward lead, to containing increased elements of management especially after my promotion to Deputy Head of Midwifery. The change in direction was the result of choices which involved self-awareness and self-efficacy, and were consistent with where I saw my role in the future.  …… Full article requires Athens account 

Amanda Lucas
Deputy Head of Midwifery and Women’s Services/Supervisor of Midwives,
Macclesfield Hospital,
East Cheshire NHS Trust

Noormohamed, MS, Neophytou, C, Jain, Y; BMJ Case Reports 2012

A 66yearold male with lower abdominal lump: an unusual presentation of an uncommon abdominal pathology

MS Noormohamed, C Neophytou, Y Jain… – BMJ Case …, 2012 –
Summary A 66-year-old Caucasian male was admitted following symptoms of intermittent umbilical pain aggravated after meals and associated with vomiting of contents. Physical examination revealed a tender, partially reducible swelling suspicious of complicated umbilical hernia. Abdominal x-ray revealed dilated small bowel loops which appeared consistent with clinical diagnosis. He underwent a laparotomy subsequently which revealed a small defect in the linea alba with viable small bowel and two firm mesenteric masses encroaching the lumen approximately two feet from the ileocaecal junction. The histology of the excised bowel and masses revealed that the tumour composed of bland spindle cells with slender to plump nuclei and eosinophilic cytoplasm. Mesenteric fibromatosis are the most common primary tumours of the mesentery and constitute about 3.5% of all fibrous tissue tumours. Intra-abdominal desmoids are very rare and benign tumours but are very aggressive and should be considered in the differential diagnosis of acute abdominal pain.

Amin,K, Jain, Y, Clarke, L, Roshanlall, C – European Journal of Surgical Oncology; 2012

Incidence of local and distant recurrence after mastectomy-a ten-year review at Macclesfield District General Hospital (MDGH)

K Amin, Y Jain, L Clarke, C Roshanlall – European Journal of Surgical …, 2012 –
European Journal of Surgical Oncology Volume 38, Issue 5 , Page 427, May 2012.
Incidence of local and distant recurrence after mastectomy – a ten-year review at Macclesfield District General Hospital (MDGH). 
No abstract available.

Patient satisfaction following mastectomy and breast reconstruction in a district general hospital

Y Jain, K Amin, J Kokan – European Journal of Surgical Oncology, 2012 –
European Journal of Surgical Oncology Volume 38, Issue 5 , Pages 429-430, May 2012.
Patient satisfaction following mastectomy and breast reconstruction in a district general hospital. 
No abstract available.

BMJ Learning modules for this week

Common problems in children 5: skin conditions

The following modules give an important update on a range of common dilemmas.

Caring for patients with bowel symptoms: in association with the NHS Cancer Screening Programmes

Suspected breast cancer: when you should refer – in association with NICE

Suspected lower gastrointestinal tract cancer: when you should refer – in association with NICE

Suspected lung cancer: when you should refer – in association with NICE

AQuA: forthcoming February events

These AQuA events are starting soon – have you booked your place?

31 Jan 2013
Advancing Quality Cheshire and Wirral CCGs locality meeting (part of Reducing avoidable mortality)
GPs and commissioners from across the Cheshire and Wirral cluster are invited to attend a locality meeting to discuss the role of CCGs in Advancing Quality (AQ). Advancing Quality is a clinically-led quality improvement programme designed to driv…

31 Jan 2013
Motivational Interviewing (part of Better Patient Experience)
See attached document for a summary of the Event and alternative dates.

04 Feb 2013 — 04 Feb 2013
Human Factors of the AQuA Improvement Methodology Plus programme

08 Feb 2013
Children & Young Peoples (part of Quality of life for people with long term conditions)
Avoiding unnecessary Hospital Admissions and inappropriate A&E attendances of Children & Young People with Long Term Conditions Following the successful launch in September, we would like to invite you to Workshop 2 of the Children & Young People’…

08 Feb 2013
Shared Decision Making – Train the Trainer (part of Better Patient Experience)
Learning Objectives are to: Increase the awareness of SDM in clinical environments Provide tools and examples of SDM language that could be used Identify potential challenges around engagement and identify solutions. Agenda Setting the scene In…

13 Feb 2013
Action Learning Set 3 (part of Integration)
Third Action learning set for the Integrated Care community 2

14 Feb 2013
Motivational Interviewing (part of Better Patient Experience)
See attached document for a summary of the Event and alternative dates

15 Feb 2013 — 15 Feb 2013
Coaching Essentials of the AQuA Improvement Methodology Plus programme
There is a half day follow up with this module which will be held on 21st March 2013 am.

15 Feb 2013
Motivational Interviewing (part of Better Patient Experience)
See attached document for a summary of the Event and alternative dates

22 Feb 2013
Motivational Interviewing (part of Better Patient Experience)
See attached document for a summary of the Event and alternative dates

25 Feb 2013 — 25 Feb 2013
Measurement of the AQuA Improvement Methodology Plus programme

26 Feb 2013 — 02 May 2013
Cohort Three of the Advanced Team Training Programme in Healthcare programme
Cohort three of the Advanced Team Training Programme in Healthcare

26 Feb 2013
Advancing Quality Programme Leads meeting of 2013 (part of Reducing avoidable mortality)
Ideally, the programme lead (or alternative representative) from each acute and mental health trust participating in the Advancing Quality programme should attend. The meetings are the most beneficial for attendees when we’ve got representation fr…

27 Feb 2013 — 05 Apr 2013
Cohort 11 of the AQuA Improvement Methodology programme

27 Feb 2013
Advancing Quality Greater Manchester CCGs locality meeting (part of Reducing avoidable mortality)
GPs and commissioners from across the Greater Manchester cluster are invited to attend a locality meeting to discuss the role of CCGs in Advancing Quality (AQ). Advancing Quality is a clinically-led quality improvement programme designed to drive…

28 Feb 2013
Unlocking Diagnosis: Sharing Good Practice in the Assessment of people with Memory Problems (part of Quality of life for people with long term conditions)
The focus of this event will be to share good practice in the assessment of people with memory problems and to provide an update from the Memory Services National Accreditation Programme


The King’s Fund Update: Jan 2013

Estates and facilities alert
This alert relates to window restrictors that may be inadequate in preventing a determined effort to force a window open beyond the 100mm restriction. This follows an incident in which a patient died following a fall from a second floor hospital window. All healthcare organisations are asked to review the guidance.

Case Report: Symptomatic cholecystolithiasis after cholecystectomy

BMJ Case Reports 2013; doi:10.1136/bcr-2012-007692

Symptomatic cholecystolithiasis after cholecystectomy

A 43-year-old woman was admitted to the gastroenterology department with colicky pain in the upper abdomen. Four years earlier, she had undergone a laparoscopic cholecystectomy because of cholecystitis. She recognised her current complaints from that previous episode. An endoscopic retrograde cholangiopancreatography showed a cavity with a diameter of 2 cm which contained multiple concrements near the liver hilus. An elective surgical exploration was performed. Near the clip of the previous cholecystectomy a bulging of the biliary tract with its own duct was visualised and resected. Histological examination of this “neo” gallbladder showed that the bulging was consistent with the formation of a reservoir secondary to bile leakage, probably caused by a small peroperative lesion of the common bile duct during the previous cholecystectomy. In conclusion, our patient presented with colicky pain caused by concrements inside a ‘neo’ gallbladder.

Click here for further reading  – Athens account required

European Radiology, July 2012; Imaging vascular function for early stage clinical trials …

Imaging vascular function for early stage clinical trials using dynamic contrast-enhanced magnetic resonance imaging
Citation: European Radiology, July 2012, vol./is. 22/7(1451-1464), 0938-7994;1432-1084 (July 2012)
Author(s): Leach M.O.; Morgan B.; Tofts P.S.; Buckley D.L.; Huang W.; Horsfield M.A.; Chenevert T.L.; Collins D.J.; Jackson A.; Lomas D.; Whitcher B.; Clarke L.; Plummer R.; Judson I.; Jones R.; Alonzi R.; Brunner T.; Koh D.M.; Murphy P.; Waterton J.C.; Parker G.; Graves M.J.; Scheenen T.W.J.; Redpath T.W.; Orton M.; Karczmar G.; Huisman H.; Barentsz J.; Padhani A.

Abstract: Many therapeutic approaches to cancer affect the tumour vasculature, either indirectly or as a direct target. Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) has become an important means of investigating this action, both pre-clinically and in early stage clinical trials. For such trials, it is essential that the measurement process (i.e. image acquisition and analysis) can be performed effectively and with consistency among contributing centres. As the technique continues to develop in order to provide potential improvements in sensitivity and physiological relevance, there is considerable scope for between-centre variation in techniques. A workshop was convened by the Imaging Committee of the Experimental Cancer Medicine Centres (ECMC) to review the current status of DCEMRI and to provide recommendations on how the technique can best be used for early stage trials. This review and the consequent recommendations are summarised here. Key Points Tumour vascular function is key to tumour development and treatment Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) can assess tumour vascular function Thus DCE-MRI with pharmacokinetic models can assess novel treatments Many recent developments are advancing the accuracy of and information from DCE-MRI Establishing common methodology across multiple centres is challenging and requires accepted guidelines.

European Society of Radiology 2012.

Publication Type: Journal: Article
Source: EMBASE

Knight, S, et al; Annals of the Rheumatic Diseases, June 2012

The influence of anti-TNF therapy upon incidence of keratinocyte skin cancer in patients with rheumatoid arthritis:    Longitudinal results from the British Society for Rheumatology Biologics Register
Citation: Annals of the Rheumatic Diseases, June 2012, vol./is. 71/6(869-874),
0003-4967;1468-2060 (June 2012)
Author(s): Mercer L.K.; Green A.C.; Galloway J.B.; Davies R.; Lunt M.; Dixon W.G.; Watson K.D.; Symmons D.P.M.; Hyrich K.L.; Maiden N.; Price T.; Hopkinson N.; O’Reilly S.; Hordon L.; Griffiths I.; Porter D.; Capell H.; Hassell A.; Benitha R.; Choy E.; Walsh D.; Emery P.; Knight S.; Bruce I.; Taggart A.; Scott D.; Thompson P.; McCrae F.; Goodfellow R.; Kitas G.; Jubb R.; Abernethy R.; Clarke S.; Green S.; Sanders P.; Coulson A.; Harrison B.; Bukhari M.; Klimiuk P.
Source: EMBASE

Heathcote, JA, Nyholm E; Journal of Family Planning & Reproductive Health Care, 2013

Foundations for the future: preparing tomorrow’s medical educators today

JA Heathcote, E Nyholm – Journal of Family Planning and .., 2013 –
Good teachers have a major influence on the quality and safety of medical care delivered to patients. As the area of sexual and reproductive health care (SRH) has evolved there has always been a strong commitment to supporting the development of sexual 

Matytsina-Quinlan L; Journal of Family Planning & Reproductive Health Care 2013

Difficult removal of a deep implant using a traditional removal method

Citation:  Journal of Family Planning & Reproductive Health Care, 01 2013, vol./is. 39/1(64-5), 1471-1893;1471-1893 (2013 Jan)

Author(s):  Matytsina-Quinlan L
Publication type: Journal Article
Source:  Medline
Full-text not immediately available but we can order this article if required.

Common painkillers and kidney failure in children

Journal of Pediatrics

Date published: 28/01/2013 17:18

Summary by: Angela Bennett

A retrospective chart review, being published in the Journal of Paediatrics reports on the number of children diagnosed with acute kidney injury caused by NSAIDs in one U.S hospital over an 11 and a half year span.

Out of 1015 children that presented with acute kidney injury, 27 were identified to have NSAID-associated acute kidney injury (2.7%). Seventy-eight percent of the 27 patients had been using NSAIDs for less than 7 days. None of the patients died or developed permanent kidney failure, but 30% of the children had evidence of mild chronic kidney damage persisting after recovery from the episode of acute kidney injury.

Fit 4 Work 10 Week Diet and Nutrition Programme!

Breakfast Cereal 3Congleton and Macclesfield Courses

  • Expert nutrition and life coaching advice plus fitness training
  • 1 hour session each week for 10 weeks
  • £50 for the full 10 weeks
  • First 30 East Cheshire Trust Staff to enrol receive £20 subsidy– so just £30 to pay!

Congleton Programme

  • Starts Thursday 7th February 2013
  • Sessions every Thursday from 17:30 until 18:30

Macclesfield Programme

  • Starts Tuesday 5th March 2013
  • Sessions every Tuesday from 17:30 until 18:30

Crewe Programme

  • Programme to start March 2013 pending amount of interest received

Click here for further details

If you would like to enrol please contact no later than 28th January for the Congleton programme and by 14th February for the Macclesfield programme.

Pilates at Congleton War Memorial and MDGH
Please email your expression of interest for the following classes to:

If enough interest is received classes would commence beginning of February -at £4 per session

Pilates Class – Tuesday Evenings, Congleton War Memorial, 17.30 until 18.30

Pilates Class – Wednesday Evenings, MDGH, 17.30 until 18.30

Pilates Class – Thursday Lunchtime, MDGH, 12.30 until 13.15

New Staff Health Promotion Activity Calendar

Take a look at our new health promotion calendar to find out more about health awareness activities in your workplace from January until April 2013.

View the Staff Health Promotion Calendar

Your Suggestions

The new Employee Wellbeing Strategy is based on the following three staff pledges which reflect East Cheshire Trusts commitment to employee wellbeing.  The Wellbeing Group meet on a monthly to discuss, develop and review actions against the following staff wellbeing pledges

  • Increase Physical Wellbeing at Work
  • Focus on Weight Management & Healthy Lifestyles
  • Increase Mental Health and Wellbeing at Work

If you have any suggestions or ideas which could help with this work or would like to be become a member of the Wellbeing Steering Group, please contact:

Eileen Platt, Wellbeing Group Chair

Wellbeing News

For more information on the following visit your Wellbeing Direct Pages

  • Staff Discounts & Schemes
  • Staff Activities & Events
  • Wellbeing Newsletters
  • Change Support Resources
  • Staff Counselling

Polite Notice:

If you are attending activities located at the Kids Allowed Nursery, please could you avoid parking on their car park where possible as spaces are required for parents collecting children. Many thanks for your understanding.

East Cheshire Trust BIG BAND

We’ve received a fantastic staff suggestion to set up an East Cheshire Trust BIG BAND.

If you play an instrument, know of a conductor or are willing to set this up for staff please contact:

111 NOT 999 for non emergencies

 “CALL 111, when it’s less urgent than 999”

This is the introduction of a FREE nationwide telephone number to deal with less urgent requests for medical advice, appointments and health issues.  111 should generally be used for minor injury or illness that requires medical attention but is not an emergency.

NHS Direct have won the contract to provide 111 in the Cheshire and Merseyside area.  There will be a “soft launch” on 21 March 2013 when the number will go live, and a full public launch will take place on 11 April 2013.


The aim of the new telephone service is to provide one simple number to dial with immediate direction to the required service and / or immediate relevant health advice.


For more information on this service click here.

Health Matters: 5 February 2013

The next Health Matters public lecture will be held on Tuesday 5 February 2013, from 7-8pm, in the Lecture Theatre, Education & Training. The talk will be presented by Dr Rubina Japanwala, Consultant Orthogeriatrician, and is entitled “Bone Health Matters, or does it?”

The aim of the talk is to increase awareness to improve bone health and to prevent falls and fractures, and will give information about osteoporosis, falls, vitamin D, and fractures.
Dr Japanwala is also the Falls Lead for the Trust.

Members of staff are very welcome to attend this interesting talk.  If you would like to attend please contact the Communications & Engagement Team on ext 1560 (01625 661560) or email us at

This article “Discrepancies in predicted fracture risk in elderly people” is published in the BMJ (Jan 2013) looks at calculators used to estimate fracture risk in elderly people which give widely different results. Mark Bolland and colleagues argue that treatment decisions should be based on calculators using 3-5 year estimates of risk.  Click for full article

Behind the Headlines added to Understanding Evidence

Behind the Headlines part of NHS Choices, provides an unbiased and evidence-based analysis of health stories that make the news.

The service is intended for both the public and health professionals, and endeavours to:

  • explain the facts behind the headlines and give a better understanding of the science that makes the news,
  • provide an authoritative resource for GPs that they can rely on when talking to patients, and
  • become a trusted resource for journalists and others involved in the dissemination of health news.

behind_headlinesBehind the Headlines is the brainchild of Sir Muir Gray, who set up the service in 2007.

This feature has now been added to our Understanding Evidence page, to enable a greater understanding of the health stories reported in the news.

First UK Meningitis B vaccine

Extract from

“FAMILIES affected by meningitis are urging the Government to make a lifesaving new vaccine against Meningitis B – one of the deadliest forms of the disease – available to all children in the UK.

The vaccine, Bexsero, developed by pharmaceutical giant Novartis, received its marketing licence from the European Commission today.

It is the first Meningitis B vaccine to be licensed for use in the UK and will save thousands of lives, especially among children under five, who are most at risk from the disease.

Meningitis B is a major issue for the UK, which has one of the highest incidence rates in the world. It is the most common form of meningitis in the UK, affecting an average of 1,8702 people each year, many of them children. One in 103 people who contract the disease will die and one in four, will be left with life-changing after-effects, such as brain damage or limb loss.

Click here for the full article


Can health apps damage your health?

Technology can be fantastic but every week sees the launch of a new smartphone or tablet app. If you have ever wondered just how beneficial the thousands of ‘health related’ apps are, then take a look at this article.  There are 3 things to bear in mind.

1 No app is better than a qualified medical professional

2 If you want an app, go to the more respected websites like Cochrane, NHS and Red Cross

3 No apps are currently regulated.

Eyes on Evidence newsletter: Issue 45, January 2013

NHS Evidence produces Eyes on Evidence – you can sign up to receive regular emails.

A retrospective case record review shows the number of preventable deaths in English NHS hospitals is unacceptably high, but not as high as previously estimated.
An analysis of the impact of New York City policy to restrict the use of trans fat for human consumption shows a significant fall in the trans fat content of fast food purchases, without a commensurate rise in the level of saturated fat. 
A systematic review and meta-analysis show that the molecular detection of tumour cells in regional lymph nodes is associated with an increased risk of disease recurrence and poor survival in patients with node-negative colorectal cancer.
Results of a randomised controlled trial show that offering either additional free nicotine replacement therapy or higher intensity proactive telephone counselling to people who rang a national helpline for support to stop smoking, did not increase quit rates over and above those obtained using standard helpline support. 
A Cochrane review concludes that antihypertensive drugs have not been shown to reduce mortality or morbidity in adults with mild hypertension and no previous cardiovascular events. Significantly more people taking antihypertensive treatment discontinued treatment due to adverse effects, compared with placebo. However, the review has some significant limitations. 
The QIPP Collection highlights examples of local best practice, demonstrating how NHS organisations have implemented new practices which have both cut costs and improved quality.